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Yang Y, Jiang H, Yang W, Wang H, Wang M, Li X, Huang P, Fang S, Hao W, Yang Y, Zhao F, He W. The IVIG treatment response in autoimmune polyendocrine syndromes type 2 with anti-GAD65 antibody-associated stiff person syndrome: a case report and literature review. Front Immunol 2025; 15:1471115. [PMID: 39840065 PMCID: PMC11746041 DOI: 10.3389/fimmu.2024.1471115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 12/12/2024] [Indexed: 01/23/2025] Open
Abstract
Autoimmune polyendocrine syndromes (APS) is a rare group of disorders caused by impaired function of multiple endocrine glands due to disruption of immune tolerance. Of which, type 2 (APS-2) is the most common. Glutamic acid decarboxylase (GAD) is the rate-limiting enzyme for the synthesis of gamma-aminobutyric acid (GABA). Anti-GAD antibodies are associated with various neurological disorders, including stiff person syndrome (SPS). SPS is characterized by axial muscle stiffness, rigidity, and intermittent painful muscle spasms, with a prevalence of one to two in a million, making it an extremely rare neurological disorder. The comorbidity of APS-2 with SPS is even rarer. Most practicing neurologists encounter only one or two cases of APS-2 combined with anti-GAD65 antibody-associated SPS in their careers, resulting in underdiagnosis and undertreatment, leading to severe disability and suffering. This case report describes a young male who initially exhibited hair loss, vitiligo, and previously unreported eosinophilia. Before his diagnosis, he was admitted multiple times, with symptoms improving following the addition of intravenous immunoglobulin (IVIG) therapy to a poor treatment regimen. This paper aims to increase physicians' awareness of this condition, enhancing the likelihood of early diagnosis and treatment.
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Affiliation(s)
- Yulong Yang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Hailin Jiang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Wenming Yang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
- Key Laboratory of Xin’An Medicine, Ministry of Education Hefei, Anhui, China
- Center for Xin’an Medicine and Modernization of Traditional Chinese Medicine, Institute of Health and Medicine Hefei Comprehensive National Science Center, Hefei, Anhui, China
| | - Han Wang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
- Key Laboratory of Xin’An Medicine, Ministry of Education Hefei, Anhui, China
| | - Meixia Wang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
- Key Laboratory of Xin’An Medicine, Ministry of Education Hefei, Anhui, China
| | - Xiang Li
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Peng Huang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Shuzhen Fang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Wenjie Hao
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Yue Yang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Furong Zhao
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
| | - Wei He
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional, Chinese Medicine, Hefei, Anhui, China
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Alobaidy A, Alsulaimi M, Alajmi A. Spectrum of neurological manifestations, existence of diabetes mellitus, and 5-year mortality and cancer association outcomes in a cohort of Omani patients with positive anti- GAD autoimmunity. Expert Rev Clin Immunol 2024; 20:1483-1492. [PMID: 39167450 DOI: 10.1080/1744666x.2024.2395853] [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: 04/24/2024] [Revised: 07/08/2024] [Accepted: 08/01/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES There is scarce data in the literature concerning the anti-GAD65 antibodies (GAD-Abs) autoimmunity in the Omani population. METHODS Retrospective cohort study included GAD-Abs positive patients (n = 444) presented to a tertiary referral center in Oman from January 2005 until January 2018, with a five-year follow-up to study the cancer association and mortality outcomes. RESULTS Out of 444 patients, 27 patients (6.1%) showed GAD-Abs related neurological disorders. Adult age group was significantly associated with more GAD-Abs related neurological manifestations compared to pediatric and adolescents age group (p = 0.045). There was no association between the presence or absence of neurological manifestations with diabetes mellitus nor the titer level of GAD-Abs. Refractory status epilepticus and stiff person syndrome were the main causes of death in patients with neurological manifestations over five years and none of them found to have associated cancer. CONCLUSION The GAD-Abs autoimmunity represents a spectrum of neurological manifestations with variable severity and outcome among Omanis with positive GAD-Abs testing. The results of this study will serve as a platform for future studies to address the impact of GAD-Abs autoimmunity on the morbidity, mortality and treatment efficacy in the Omani population.
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Affiliation(s)
- Ammar Alobaidy
- Department of Medicine- Neurology Unit, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mulham Alsulaimi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Ameer Alajmi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Wang Y, Hu C, Aljarallah S, Reyes Mantilla M, Mukharesh L, Simpson A, Roy S, Harrison K, Shoemaker T, Comisac M, Balshi A, Obando D, Maldonado DAP, Koshorek J, Snoops S, Fitzgerald KC, Newsome SD. Expanding clinical profiles and prognostic markers in stiff person syndrome spectrum disorders. J Neurol 2024; 271:1861-1872. [PMID: 38078976 PMCID: PMC10973082 DOI: 10.1007/s00415-023-12123-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To describe the clinical features of a cohort of individuals with stiff person syndrome spectrum disorders (SPSD) and identify potential early predictors of future disability. BACKGROUND There is a need to better understand the full spectrum of clinical and paraclinical features and long-term impact of SPSD. DESIGN/METHODS Observational study from 1997 to 2022 at Johns Hopkins. Clinical phenotypes included classic SPS, partial SPS (limb or trunk limited), SPS-plus (classic features plus cerebellar/brainstem involvement), and progressive encephalomyelitis with rigidity and myoclonus (PERM). Outcome measures were modified Rankin scale (mRS) and use of assistive device for ambulation. Multivariate logistic regression was used to assess significant predictors of outcomes. RESULTS Cohort included 227 individuals with SPSD with mean follow-up of 10 years; 154 classic, 48 SPS-plus, 16 PERM, and 9 partial. Mean age at symptom onset was 42.9 ± 14.1 years, majority were white (69.2%) and female (75.8%). Median time to diagnosis was 36.2 months (longest for SPS-plus and PERM) and 61.2% were initially misdiagnosed. Most had systemic co-morbidities and required assistive devices for ambulation. Female sex (OR 2.08; CI 1.06-4.11) and initial brainstem/cerebellar involvement (OR 4.41; CI 1.63-14.33) predicted worse outcome by mRS. Older age at symptom onset (OR 1.04; CI 1.01-1.06), female sex (OR 1.99; CI 1.01-4.01), Black race (OR 4.14; CI 1.79-10.63), and initial brainstem/cerebellar involvement (OR 2.44; CI 1.04-7.19) predicted worse outcome by use of assistive device. Early implementation of immunotherapy was associated with better outcomes by either mRS (OR 0.45; CI 0.22-0.92) or use of assistive device (OR 0.79; CI 0.66-0.94). CONCLUSIONS We present the expanding phenotypic variability of this rare spectrum of disorders and highlight potential predictors of future disability.
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Affiliation(s)
- Yujie Wang
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Chen Hu
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Salman Aljarallah
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Maria Reyes Mantilla
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Loulwah Mukharesh
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Simpson
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Shuvro Roy
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kimystian Harrison
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Thomas Shoemaker
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Michael Comisac
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Alexandra Balshi
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Danielle Obando
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Daniela A Pimentel Maldonado
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Jacqueline Koshorek
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Sarah Snoops
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
| | - Kathryn C Fitzgerald
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Scott D Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD, 21287, USA.
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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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Fakhari MS, Poorsaadat L, Mohammad Talebi H, Kosari F. Stiff-person syndrome revealing an occult gray zone lymphoma: A diagnostic challenge. Clin Case Rep 2023; 11:e8328. [PMID: 38098799 PMCID: PMC10720256 DOI: 10.1002/ccr3.8328] [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: 08/10/2023] [Revised: 09/25/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
Key Clinical Message Stiff-Person Syndrome (SPS) can be associated with various malignancies, including lymphomas. Therefore, clinicians should always remain vigilant for the presence of an underlying malignancy, especially in older patients presenting with SPS. Abstract Stiff-person syndrome (SPS) is a rare neurological disorder characterized by painful muscle spasms. It can occur as a paraneoplastic syndrome associated with various malignancies. We present a case of an older male adult with a history of recurrent fever episodes and elevated inflammatory markers for 1 year who subsequently developed neurological symptoms. The presence of positive amphiphysin antibodies led to the diagnosis of SPS, which prompted further investigations revealing an underlying Gray Zone lymphoma (GZL). This case highlights the challenges in diagnosing lymphoma and emphasizes the importance of considering SPS as a paraneoplastic syndrome in guiding toward the final diagnosis. The diagnostic challenge in our case is summarized in Chart 1.
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Affiliation(s)
| | - Leila Poorsaadat
- Department of Neurology, School of MedicineArak University of Medical SciencesArakIran
| | | | - Farid Kosari
- Department of Pathology, School of MedicineTehran University of Medical SciencesTehranIran
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Peng Y, Yang H, Xue YH, Chen Q, Jin H, Liu S, Yao SY, Du MQ. An update on malignant tumor-related stiff person syndrome spectrum disorders: clinical mechanism, treatment, and outcomes. Front Neurol 2023; 14:1209302. [PMID: 37859648 PMCID: PMC10582361 DOI: 10.3389/fneur.2023.1209302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023] Open
Abstract
Stiff person syndrome (SPS) is a rare central nervous system disorder associated with malignancies. In this review, we retrieved information from PubMed, up until August 2023, using various search terms and their combinations, including SPS, stiff person syndrome spectrum disorders (SPSSDs), paraneoplastic, cancer, and malignant tumor. Data from peer-reviewed journals printed in English were organized to explain the possible relationships between different carcinomas and SPSSD subtypes, as well as related autoantigens. From literature searching, it was revealed that breast cancer was the most prevalent carcinoma linked to SPSSDs, followed by lung cancer and lymphoma. Furthermore, classic SPS was the most common SPSSD subtype, followed by stiff limb syndrome and progressive encephalomyelitis with rigidity and myoclonus. GAD65 was the most common autoantigen in patients with cancer and SPSSDs, followed by amphiphysin and GlyR. Patients with cancer subtypes might have multiple SPSSD subtypes, and conversely, patients with SPSSD subtypes might have multiple carcinoma subtypes. The first aim of this review was to highlight the complex nature of the relationships among cancers, autoantigens, and SPSSDs as new information in this field continues to be generated globally. The adoption of an open-minded approach to updating information on new cancer subtypes, autoantigens, and SPSSDs is recommended to renew our database. The second aim of this review was to discuss SPS animal models, which will help us to understand the mechanisms underlying the pathogenesis of SPS. In future, elucidating the relationship among cancers, autoantigens, and SPSSDs is critical for the early prediction of cancer and discovery of new therapeutic modalities.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Shun-yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
| | - Miao-qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
- The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, Hunan, China
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Lim TT, Por CY, Beh YY, Schee JP, Tan AH. Treatment of startle and related disorders. Clin Park Relat Disord 2023; 9:100218. [PMID: 37808566 PMCID: PMC10556813 DOI: 10.1016/j.prdoa.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/04/2023] [Accepted: 09/15/2023] [Indexed: 10/10/2023] Open
Affiliation(s)
| | - Chia Yin Por
- Department of Medicine, Penang General Hospital, Penang, Malaysia
| | - Yuan Ye Beh
- Department of Medicine, Penang General Hospital, Penang, Malaysia
| | - Jie Ping Schee
- Faculty of Medicine (Divisions of Neurology), University of Malaya, Malaysia
| | - Ai Huey Tan
- Faculty of Medicine (Divisions of Neurology), University of Malaya, Malaysia
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Aryal R, Shrestha S, Homagain S, Tiwari SB, Ojha R. Intravenous immunoglobulin in the management and outcome of Stiff‐Person syndrome: A systematic review. CLINICAL AND EXPERIMENTAL NEUROIMMUNOLOGY 2022; 13:302-315. [DOI: 10.1111/cen3.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/16/2022] [Indexed: 10/02/2024]
Abstract
AbstractBackgroundStiff Person Syndrome (SPS), a rare immune‐mediated neuromuscular disorder, is characterized by rigidity, stiffness, and intermittent spasms of axial and extremity muscles. Various immunotherapies including intravenous immunoglobulin (IVIG) have been used for this autoimmune condition. Here we aim to review the role of IVIG in the treatment of SPS along with its outcome.MethodsA systematic literature search of PubMed and Embase was conducted to identify the relevant published articles against the predefined criteria using suitable keywords combinations till September 20, 2021. Data were extracted to produce descriptive information of SPS patients on demographics, diagnostics, treatment with IVIG, and outcome.ResultsTwelve studies with 216 patients were included in the review and 63.89% of them had classical SPS. Glutamic acid decarboxylase (GAD) autoantibodies were present in 72.68% of the patients and 57.89% in whom electromyography (EMG) was performed had continuous motor activity. IVIG therapy was given to 95 patients in different regimens in various studies and varying scoring systems were used to assess the outcome, and 83.16% showed some form of improvement, 14.74% showed no improvement, while 2.10% worsened. None of the included studies mentioned an adverse effect of IVIG in the patients.ConclusionIVIG may benefit patients with SPS along with other medications. Owing to the rarity of the disease and insufficient studies on the assessment of immunotherapy in SPS, longitudinal studies with a sizable number of patients are required to clarify clinical course, treatment, and outcome in SPS with the use of IVIG.
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Affiliation(s)
- Roshan Aryal
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Suraj Shrestha
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Sushan Homagain
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Sansar Babu Tiwari
- Department of Pathology Tribhuvan University Teaching Hospital Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Kathmandu Nepal
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Dalakas MC, Latov N, Kuitwaard K. Intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): mechanisms of action and clinical and genetic considerations. Expert Rev Neurother 2022; 22:953-962. [PMID: 36645654 DOI: 10.1080/14737175.2022.2169134] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune peripheral nerve disorder that is characterized by subacute onset, progressive or relapsing weakness, and sensory deficits. Proven treatments include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. This review focuses on the mechanisms of action, pharmacodynamics, genetic variations, and disease characteristics that can affect the efficacy of IVIg. AREAS COVERED The proposed mechanisms of action of IVIg that can mediate its therapeutic effects are reviewed. These include anti-idiotypic interactions, inhibition of neonatal Fc receptors (FcRn), anti-complement activity, upregulation of inhibitory FcγRIIB receptors, and downregulation of macrophage activation or co-stimulatory and adhesion molecules. Clinical and genetic factors that can affect the therapeutic response include misdiagnosis, degree of axonal damage, pharmacokinetic variability, and genetic variations. EXPERT OPINION The mechanisms of action of IVIg in CIDP and their relative contribution to its efficacy are subject of ongoing investigation. Studies in other autoimmune neurological conditions, in addition, highlight the role of key immunopathological pathways and factors that are likely to be affected. Further investigation into the pathogenesis of CIDP and the mechanisms of action of IVIg may lead to the development of improved diagnostics, better utilization of IVIg, and more targeted and effective therapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson Neuroimmunology Unit, Philadelphia, PA and National and Department of Pathophysiology, Kapodistrian University of Athens, Greece
| | - Norman Latov
- Neuroimmunology Unit, Weill Cornell Medical College, New York, NY, USA
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Kassavetis P, Kaski D, Anderson T, Hallett M. Eye Movement Disorders in Movement Disorders. Mov Disord Clin Pract 2022; 9:284-295. [PMID: 35402641 PMCID: PMC8974874 DOI: 10.1002/mdc3.13413] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/24/2021] [Accepted: 12/03/2021] [Indexed: 11/05/2022] Open
Abstract
Oculomotor assessment is an essential element of the neurological clinical examination and is particularly important when evaluating patients with movements disorders. Most of the brain is involved in oculomotor control, and thus many neurological conditions present with oculomotor abnormalities. Each of the different classes of eye movements and their features can provide important information that can facilitate differential diagnosis. This educational review presents a clinical approach to eye movement abnormalities that are commonly seen in parkinsonism, ataxia, dystonia, myoclonus, tremor, and chorea. In parkinsonism, subtle signs such as prominent square wave jerks, impaired vertical optokinetic nystagmus, and/or the "round the houses" sign suggest early progressive supranuclear gaze palsy before vertical gaze is restricted. In ataxia, nystagmus is common, but other findings such as oculomotor apraxia, supranuclear gaze palsy, impaired fixation, or saccadic pursuit can contribute to diagnoses such as ataxia with oculomotor apraxia, Niemann-Pick type C, or ataxia telangiectasia. Opsoclonus myoclonus and oculopalatal myoclonus present with characteristic phenomenology and are usually easy to identify. The oculomotor exam is usually unremarkable in isolated dystonia, but oculogyric crisis is a medical emergency and should be recognized and treated in a timely manner. Gaze impersistence in a patient with chorea suggests Huntington's disease, but in a patient with dystonia or tremor, Wilson's disease is more likely. Finally, functional eye movements can reinforce the clinical impression of a functional movement disorder.
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Affiliation(s)
- Panagiotis Kassavetis
- National Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
- Department of NeurologyUniversity of UtahSalt Lake CityUtahUSA
| | - Diego Kaski
- Centre for Vestibular and Behavioural Neurosciences, Department of Clinical and Movement NeurosciencesUniversity College London, Institute of NeurologyLondonUK
| | - Tim Anderson
- New Zealand Brain Research InstituteChristchurchNew Zealand
- Department of MedicineUniversity of OtagoChristchurchNew Zealand
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
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Bose S, Thompson JP, Sadalage G, Karim A, Jacob S. Quantitative Assessment of Response to Long-Term Treatment with Intravenous Immunoglobulin in Patients with Stiff Person Syndrome. Mov Disord Clin Pract 2021; 8:868-874. [PMID: 34401404 PMCID: PMC8354084 DOI: 10.1002/mdc3.13261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022] Open
Abstract
Background Stiff person syndrome (SPS) is an autoimmune condition involving antibodies against several components of the inhibitory synapse in the spinal cord, with glutamic acid decarboxylase antibodies being the predominant immune marker. SPS affects approximately 1 patient per million population per year. The effect of intravenous immunoglobulin (IVIG) has been established, but studies on the long-term efficacy of regular IVIG are limited. Objectives To review clinical details and long-term treatment response using a patient-reported questionnaire in SPS and related syndromes. Methods Patients were identified from a tertiary neuroimmunology clinic based on classical clinical symptoms, autoimmune profiles, and neurophysiological changes (Dalakas criteria). They were followed up after treatment to assess the response to IVIG. Results A total of 23 patients fulfilled the selection criteria. Patients' demographic profiles and clinical presentations were akin to that reported in literature. There was significant improvement in the functional ability (assessed by the modified Rankin scale [mRS]) and quality of life (QoL) following treatment with IVIG within 4 to 10 weeks (pre-mRS vs. post-mRS, P < 0.0001; pre-QoL vs. post-QoL, P = 0.0003) and sustained after 5 years of treatment (pre-mRS vs. present mRS, P = 0.0003; pre-QoL vs. present QoL, P = 0.0002). Conclusions This article describes one of the largest single-center experiences of 23 patients with SPS and related syndromes and is the first to establish the long-term efficacy of regular IVIG using a patient-reported scoring system (Birmingham Response to Immunomodulatory Therapy [BRIT]). Consistent improvement in QoL and functional scores were seen over nearly 5 years after regular use of IVIG. It is recommended to use BRIT scores to assess the initial response as well as to monitor continued improvement to immunomodulation in SPS.
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Affiliation(s)
- Smriti Bose
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Joseph P Thompson
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Girija Sadalage
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom
| | - Abid Karim
- Clinical Immunology Service University of Birmingham Birmingham United Kingdom
| | - Saiju Jacob
- Department of Neurology University Hospitals Birmingham Birmingham United Kingdom.,Institute of Immunology and Immunotherapy University of Birmingham Birmingham United Kingdom
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12
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Ortiz JF, Ghani MR, Morillo Cox Á, Tambo W, Bashir F, Wirth M, Moya G. Stiff-Person Syndrome: A Treatment Update and New Directions. Cureus 2020; 12:e11995. [PMID: 33437550 PMCID: PMC7793517 DOI: 10.7759/cureus.11995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Stiff-person syndrome (SPS) is a rare and disabling central nervous system disorder with no satisfactory treatment. Muscle rigidity, sporadic muscle spasms, and chronic muscle pain characterize SPS. SPS is strongly correlated with autoimmune diseases, and it is usual to find high titers of antibodies against acid decarboxylase (GAD65). Due to its highly disabling nature and complicated treatment, we aim to create a treatment protocol through a narrative review of currently available treatments that show efficacy. We expect to facilitate management based on treatment responses ranging from first-line medication to refractory medication. We conducted a medical subject heading (MeSH) strategy. We used the term SPS with the subheading treatment: "Stiff-Person Syndrome/Therapy" [MeSH]. An initial data gathering of 270 papers came out with the initial research. After using the inclusion criteria, we had 159 articles. We excluded 31 papers for being either systematic reviews, literature reviews, or meta-analysis. From the 128 remaining articles, we excluded another 104 papers because the extraction of the data was not possible or the study outcome did not meet our demands. There are two main treatments for SPS: GABAergic (gamma-aminobutyric acid) therapy and immunotherapy. For treatment, we suggest starting with benzodiazepines as first-line treatment. We recommend adding levetiracetam or pregabalin if symptoms persist. As second-line therapy, we recommend oral baclofen over rituximab and tacrolimus. We also suggest rituximab over tacrolimus. For patients with refractory treatment, we can use intrathecal baclofen, intravenous immunoglobulin (IVIG), or plasmapheresis. We conclude that intrathecal baclofen and IVIG are more effective than plasmapheresis in patients with refractory symptoms. Propofol may be used as a bridge - temporary therapy before initiating a permanent treatment.
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Affiliation(s)
- Juan Fernando Ortiz
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohammad R Ghani
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Willians Tambo
- Neurology, Universidad San Francisco de Quito, Quito, ECU
| | - Farah Bashir
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Martín Wirth
- Neurology, Universidad San Francisco de Quito, Quito, ECU
| | - Gustavo Moya
- Medicine, Carlos Andrade Marín Hospital, Quito, ECU
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13
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Dade M, Berzero G, Izquierdo C, Giry M, Benazra M, Delattre JY, Psimaras D, Alentorn A. Neurological Syndromes Associated with Anti-GAD Antibodies. Int J Mol Sci 2020; 21:E3701. [PMID: 32456344 PMCID: PMC7279468 DOI: 10.3390/ijms21103701] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Glutamic acid decarboxylase (GAD) is an intracellular enzyme whose physiologic function is the decarboxylation of glutamate to gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter within the central nervous system. GAD antibodies (Ab) have been associated with multiple neurological syndromes, including stiff-person syndrome, cerebellar ataxia, and limbic encephalitis, which are all considered to result from reduced GABAergic transmission. The pathogenic role of GAD Ab is still debated, and some evidence suggests that GAD autoimmunity might primarily be cell-mediated. Diagnosis relies on the detection of high titers of GAD Ab in serum and/or in the detection of GAD Ab in the cerebrospinal fluid. Due to the relative rarity of these syndromes, treatment schemes and predictors of response are poorly defined, highlighting the unmet need for multicentric prospective trials in this population. Here, we reviewed the main clinical characteristics of neurological syndromes associated with GAD Ab, focusing on pathophysiologic mechanisms.
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Affiliation(s)
- Maëlle Dade
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Giulia Berzero
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
- Neuroncology Unit, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Izquierdo
- Department of Neuroscience, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Marine Giry
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Marion Benazra
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Jean-Yves Delattre
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Dimitri Psimaras
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
| | - Agusti Alentorn
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin, 75013 Paris, France; (M.D.); (G.B.); (J.-Y.D.); (D.P.)
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013 Paris, France; (M.G.); (M.B.)
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14
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Zappaterra M, Shouse E, Levine RL. Low-Dose Naltrexone reduces symptoms in Stiff-Person Syndrome. Med Hypotheses 2020; 137:109546. [PMID: 31954293 DOI: 10.1016/j.mehy.2019.109546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/31/2019] [Indexed: 12/26/2022]
Abstract
Stiff-Person Syndrome (SPS) is a rare neurologic disorder characterized by severe and progressively worsening muscle stiffness and rigidity. SPS can be very painful due to unpredictable muscle spasms which can be triggered by various stimuli, such as noise, touch, or emotional experiences. There is thought to be an autoimmune component to the disorder. We present the case of a 59-year-old woman diagnosed with SPS who appears to have experienced a dramatic reduction in her symptoms after being treated with Low-Dose Naltrexone (LDN). Prior to this treatment regimen, she had tried many treatments with only limited derived benefit. She was started on LDN and after 6 weeks, reported reductions in pain, anxiety, depression, agoraphobia, and muscle tightness. Upon multiple follow-ups, leading up to 12 months, she continually displayed reduced symptoms and improved quality of life. We conclude that LDN may have some utility in treating and managing the symptoms of SPS. We hypothesize that this may be possible due to LDN operating via anti-inflammatory pathways as well as acting as an opioid antagonist. We assert that further research as it relates to LDN and SPS in addition to other chronic pain conditions is warranted.
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Affiliation(s)
- Mauro Zappaterra
- Synovation Medical Group, Pasadena, CA 91105, USA; Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA.
| | - Elizabeth Shouse
- Harmonae Psychological Services, Inc., 130 S. Euclid Ave, Suite 8, Pasadena, CA 91101, USA.
| | - Reed Loring Levine
- Synovation Medical Group, Pasadena Rehabilitation Institute, 1017 S. Fair Oaks Ave, Pasadena, CA 91105, USA.
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15
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El-Abassi R, Soliman MY, Villemarette-Pittman N, England JD. SPS: Understanding the complexity. J Neurol Sci 2019; 404:137-149. [PMID: 31377632 DOI: 10.1016/j.jns.2019.06.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/31/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stiff-person syndrome (SPS), first described in 1956 by Moersch and Woltman, is a progressive autoimmune disorder with core features of chronic fluctuating progressive truncal and limb rigidity and painful muscle spasms leading to gait difficulties, falls and an appearance that resembles tin soldiers. The syndrome is a rare, highly disabling disorder of the central nervous and frequently results in significant disability. Understanding of the etiology, clinical spectrum, diagnostic workup and therapeutic modalities for this painful and disabling disorder has vastly evolved over the past few years with more confidence in classifying and treating the patients. The purpose of this review is to increase the awareness, early detection, and treatment of this disabling disease. METHOD PubMed was searched, all date inclusive, using the following phrases: stiff person syndrome,anti-Glutamic acid decarboxylase (Anti-GAD) antibody syndrome, Progressive encephalomyelitis with rigidity and myoclonus (PERM), and Paraneoplastic Stiff Person syndrome. No filters or restrictions were used. A total of 888 articles were identified. RESULTS The results were narrowed to 190 citations after excluding non-English and duplicate reports. Clinical presentation, laboratory testing, treatment, and prognosis were categorized and summarized. DISCUSSION In this article we will discuss the epidemiology, presentation and classification. Explain the pathophysiology of SPS and the autoimmune mechanisms involved. Discuss the diagnostic approach and treatments available, as well as, the prognosis and outcome.
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Affiliation(s)
- Rima El-Abassi
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA.
| | - Michael Y Soliman
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
| | | | - John D England
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
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16
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Yilmaz FM, Little D, Gallagher M, Colcher A. Anti-glutamate Dehydrogenase Antibody Positive Cerebellar Ataxia and Stiff Person Syndrome Responding to Dual Treatment with Steroids and Intravenous Immunoglobulin: A Case Presentation and Literature Review. Cureus 2019; 11:e4851. [PMID: 31410334 PMCID: PMC6684109 DOI: 10.7759/cureus.4851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Anti-glutamic acid decarboxylase (anti-GAD) antibody syndrome (aGAS) has various presentations including cerebellar ataxia (CA) and stiff person syndrome (SPS). This is a treatable cause of CA and SPS. We present a case of a 49-year-old man who developed blurred vision, slurred speech, difficulty walking, unsteady gait, and clumsiness which had progressed over four months. The patient was found to have anti-GAD ab (+) CA and SPS and experienced significant symptomatic improvements after treatment with intravenous (IV) steroids followed by intravenous immunoglobulin (IVIG). The patient’s improvement persisted when he was reevaluated at follow up one month later. Since anti-GAD ab related diseases, including anti-GAD CA and SPS, are rarely diagnosed, there is limited data regarding the treatment of this condition. As there are only a few cases in the literature similar to this one, highlighting the successful treatment of anti-GAD ab cerebellar ataxia and SPS with dual therapy (steroids followed by IVIG) is important.
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Affiliation(s)
- Furkan M Yilmaz
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Dena Little
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Micheal Gallagher
- Neurophysiology, University of Maryland Medical Center, Baltimore, USA
| | - Amy Colcher
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
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17
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Anti-glutamic acid decarboxylase (GAD) positive cerebellar Ataxia with transitioning to progressive encephalomyelitis with rigidity and myoclonus (PERM), responsive to immunotherapy: A case report and review of literature. J Neuroimmunol 2019; 332:135-137. [PMID: 31015081 DOI: 10.1016/j.jneuroim.2019.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 01/14/2023]
Abstract
We present a case of a 65-year-old African American male, immunosuppressed on Tacrolimus, who initially presented with cerebellar ataxia and rapidly developed Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM) with positive anti-glutamic acid decarboxylase (GAD65) antibodies, no underlying malignancy, and normal neuroimaging. PERM is a rare spectrum of Stiff Person Syndrome (SPS), which is strongly associated with anti-GAD antibodies and characterized by flare-ups and remissions of encephalopathy, myelopathy and rigidity with myoclonus. PERM is diagnosed clinically and has been successfully treated with both Intravenous Immunoglobulin (IVIg) and plasmapheresis. Our patient was successfully treated with IVIg. On day 14 after starting IVIg treatment, his neurological symptoms started to improve and ultimately returned to baseline.
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18
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Galli JR, Austin SD, Greenlee JE, Clardy SL. Stiff person syndrome with Anti-GAD65 antibodies within the national veterans affairs health administration. Muscle Nerve 2018; 58:801-804. [PMID: 30192027 DOI: 10.1002/mus.26338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/26/2018] [Accepted: 09/01/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Stiff person syndrome (SPS) is a neurological disorder characterized by muscle rigidity primarily in the truncal muscles, commonly associated with autoantibodies to the glutamic acid-decarboxylase 65 kD receptor (GAD65). There is limited epidemiological information on patients with SPS. METHODS We performed a retrospective case review using the National United States Veterans Affairs Health Administration electronic medical record system. We analyzed prevalence, demographics, disease characteristics, and treatment outcomes in SPS patients who were anti-GAD65 antibody positive. RESULTS Fifteen patients met our criteria. Point prevalence was 2.06 per million, and period prevalence was 2.71 per million. Men to women ratio was 14:1. All patients benefitted from treatment with symptomatic antispasmodic agents. Ten of 15 patients received intravenous immunoglobulin, with a majority demonstrating stable or improved modified Rankin scores. DISCUSSION This investigation was a large North American epidemiological study of SPS with predominantly male patients. Symptomatic therapy was beneficial for most patients, with less clear sustained benefit of immunotherapy. Muscle Nerve 58:801-804, 2018.
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Affiliation(s)
- Jonathan R Galli
- Department of Neurology, University of Utah, Imaging and Neurosciences Center, 729 Arapeen Drive, Salt Lake City, Utah, 84108, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Sharon D Austin
- Department of Neurology, University of Utah, Imaging and Neurosciences Center, 729 Arapeen Drive, Salt Lake City, Utah, 84108, USA
| | - John E Greenlee
- Department of Neurology, University of Utah, Imaging and Neurosciences Center, 729 Arapeen Drive, Salt Lake City, Utah, 84108, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Imaging and Neurosciences Center, 729 Arapeen Drive, Salt Lake City, Utah, 84108, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
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19
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Progressive Encephalomyelitis With Rigidity and Myoclonus Syndrome Presenting as Catatonia. PSYCHOSOMATICS 2018; 60:83-87. [PMID: 30143326 DOI: 10.1016/j.psym.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/30/2022]
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20
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 415] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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21
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Ganelin-Cohen E, Modan-Moses D, Hemi R, Kanety H, Ben-zeev B, Hampe CS. Epilepsy and behavioral changes, type 1 diabetes mellitus and a high titer of glutamic acid decarboxylase antibodies. Pediatr Diabetes 2016; 17:617-622. [PMID: 26711844 PMCID: PMC4927419 DOI: 10.1111/pedi.12346] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 11/30/2022] Open
Abstract
Autoantibodies to the 65 kDa isoform of glutamate acid decarboxylase (GAD65Ab) are associated with a range of clinical disorders, including type 1 diabetes (T1D) and stiff-person syndrome (SPS). In this article we describe a young girl who was diagnosed with T1D at the end of her first year of life and developed drug-resistant epilepsy 18 months later, followed by behavioral disturbances. She was admitted to our center at the age of 5 yr, at which time high GAD65Ab titers were detected in the patient's serum and cerebrospinal fluid (CSF). The titer remained elevated during 19 months of follow-up. Furthermore, GAD65Ab in both serum and CSF showed epitope binding characteristics similar to those observed for GAD65Ab in SPS patients, and GAD65Ab in the serum reduced GAD65 enzyme activity. Our results suggest an association between high GAD65Ab titers and epilepsy in children with T1D. Careful titration and characterization of GAD65Ab regarding inhibition of enzyme activity and epitope specificity may be helpful in identifying T1D patients at risk for neurological complications.
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Affiliation(s)
- Esther Ganelin-Cohen
- Pediatric Neurology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel. .,The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - Dalit Modan-Moses
- The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel,Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Rina Hemi
- Institute of Endocrinology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Hannah Kanety
- Institute of Endocrinology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Bruria Ben-zeev
- Pediatric Neurology Unit, The Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Ramat-Gan, Israel,The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Christiane S. Hampe
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
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22
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Chang T, Lang B, Vincent A. Stiff person syndrome in South Asia. BMC Res Notes 2016; 9:468. [PMID: 27756410 PMCID: PMC5070143 DOI: 10.1186/s13104-016-2276-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stiff person syndrome is a highly disabling, progressive autoimmune disorder of the central nervous system characterized by muscle rigidity and spasms. Stiff person syndrome is rare, but is believed to be under diagnosed with only 14 cases been reported among a 1.7 billion population in South Asia. We report the first authenticated case from Sri Lanka. CASE PRESENTATION A 55-year-old Sri Lankan female presented with difficulty in walking and recurrent falls due to progressive muscular rigidity in her lower limbs and trunk with superimposed muscle spasms that occurred in response to unexpected noise, startle or emotional upset. She had anxiety and specific phobias to open spaces, walking unaided and being among crowds of people. She had insulin-dependent diabetes mellitus and was on thyroxine replacement. On examination, she had hyperlordosis combined with board-like rigidity of her anterior abdomen and rigidity of her lower limbs bilaterally. Upper limbs were normal. Magnetic resonance imaging of her neuraxis was normal. Electromyography showed continuous motor unit activity at rest. Glutamic acid decarboxylase antibodies were detected in her serum at a titre of 15,500 IU/ml (normal <5). She showed a remarkable and sustained improvement to treatment with intravenous immunoglobulins, immunosuppressive and muscle relaxant medications, regaining independent ambulation. CONCLUSIONS Diagnosis of stiff person syndrome remains clinical, supported by electromyography and serology for glutamic acid decarboxylase antibodies, facilitated by a high index of clinical suspicion. An autoimmune basis lends stiff person syndrome amenable to treatment highlighting the importance of diagnosis. This case adds to map the worldwide distribution of stiff person syndrome.
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Affiliation(s)
- Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo, 00800, Sri Lanka.
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 5/6 West Wing, Oxford, OX3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 5/6 West Wing, Oxford, OX3 9DU, UK
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Qian L, Chen W, Qin H, Rui C, Jia X, Fu Y, Gong W, Tian F, Ji M. Immune complex negatively regulates Toll-like receptor 9-mediated immune responses in B cells through the inhibitory Fc-gamma receptor IIb. Microbiol Immunol 2016; 59:142-51. [PMID: 25557539 DOI: 10.1111/1348-0421.12224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/10/2014] [Accepted: 12/25/2014] [Indexed: 01/30/2023]
Abstract
Because inappropriate activation of Toll-like receptor 9 (TLR9) may induce pathological damage, negative regulation of the TLR9-triggered immune response has attracted considerable attention. Nonpathogenic immune complex (IC) has been demonstrated to have beneficial therapeutic effects in some kinds of autoimmune diseases. However, the role of IC in the regulation of TLR9-triggered immune responses and the underlying mechanisms remain unclear. In this study, it was demonstrated that IC stimulation of B cells not only suppresses CpG-oligodeoxynucleotide (CpG-ODN)-induced pro-inflammatory IL-6 and IgM κ production, but also attenuates CD40 and CD80 expression. Furthermore, our results suggest that the receptor for the Fc portion of IgG (FcγR) IIb is involved in the suppressive effect of IC on TLR9-mediated CD40, CD80 and IL-6 expression. Finally, it was found that IC down-regulates TLR9 expression in CpG-ODN activated B cells. Our results provide an outline of a new pathway for the negative regulation of TLR9-triggered immune responses in B cells via FcγRIIb. A new mechanistic explanation of the therapeutic effect of nonpathogenic IC on inflammatory and autoimmune diseases is also provided.
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Affiliation(s)
- Li Qian
- Laboratory of Immunology, Yangzhou University School of Medicine, Yangzhou 225001; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou 225009; Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou 225001
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Immunomodulation for treatment of drug and device refractory gastroparesis. RESULTS IN IMMUNOLOGY 2016; 6:11-4. [PMID: 27014566 PMCID: PMC4792859 DOI: 10.1016/j.rinim.2016.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/16/2016] [Accepted: 02/25/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients with generalized autoimmune dysautonomia may also present with gastroparesis. Immune dysfunction in such patients can be evaluated using antibodies to glutamic acid decarboxylase (GAD) and full thickness biopsy of stomach. In this study, we utilize immunotherapy for treatment of drug and Gastric Electrical Stimulation (GES) resistant gastroparetic patients with evidence of neuroinflammation on full thickness gastric biopsy and had positive GAD65 autoantibodies. MATERIAL AND METHODS We conducted a retrospective chart review of 11 female patients with drug and device resistant gastroparesis. Patients were treated for a total of 8-12 weeks with either intravenous immunoglobulin (IVIg), or combined mycophenolate mofetil (MM) and methylprednisolone, or only MM. Patients were excluded if they had previous side effects from steroid therapy, low scores on dual-energy X-ray absorptiometry (DEXA) scan results, immune-compromised conditions with infections like tuberculosis and zoster. Symptoms of nausea, vomiting, abdominal pain, early satiety/anorexia, bloating and total symptom score (TSS) as reported by the patients were recorded before and after the treatment at a follow up visit 2 to 16 weeks after initiation of therapy. RESULTS Maximum symptom improvement was seen in patients treated with IVIg (67%). 6 patients (55%) had improvement in vomiting, whereas 5 patients (45%) had improvements in nausea, abdominal pain and bloating. CONCLUSIONS Immunomodulatory therapy shows positive outcomes in improving vomiting symptom in some gastroparetic patients who have coexisting positive autoimmune profiles. This preliminary data suggests the need for further investigations in immunotherapy targeted to patients with gastroparetic symptoms refractory to approved drug and device therapies.
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Farooq AV, Soin K, Moss HE. Alternating skew deviation in association with anti-glutamic acid decarboxylase antibodies. Neuroophthalmology 2015; 39:140-143. [PMID: 26594078 DOI: 10.3109/01658107.2015.1011755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The presence of an elevated anti-glutamic acid decarboxylase (GAD) antibody level has been associated with a number of eye movement abnormalities, as well as other findings including cerebellar ataxia and insulin dependent diabetes mellitus. Skew deviation in association with anti-GAD antibodies has not been previously reported. Here we report a case of alternating skew deviation along with cerebellar-brainstem signs in a patient with an elevated anti-GAD antibody titer. Follow-up neurologic evaluation after treatment with intravenous immunoglobulin revealed improvement in cerebellar-brainstem signs, while ophthalmic evaluation was stable.
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Affiliation(s)
- Asim V Farooq
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ketki Soin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Heather E Moss
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
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Acquired ataxias: the clinical spectrum, diagnosis and management. J Neurol 2015; 262:1385-93. [DOI: 10.1007/s00415-015-7685-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 12/29/2022]
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Therapeutic approaches in antibody-associated central nervous system pathologies. Rev Neurol (Paris) 2014; 170:587-94. [PMID: 25189679 DOI: 10.1016/j.neurol.2014.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 07/25/2014] [Indexed: 12/21/2022]
Abstract
Initially, antibodies targeting intracellular compounds were described in patients with paraneoplastic neurological syndromes (PNS) such as anti-Hu, anti-Yo, anti-Ri or anti-CV2/CRMP5 antibodies. As more than 90% of patients with these antibodies suffer from an associated cancer, these antibodies were used as biomarkers of an underlying tumour. Recently, autoantibodies targeting cell-surface synaptic antigens have been described in patients with neurological symptoms suggesting PNS. These autoantibodies being less frequently associated with a tumour, they completely changed the concept of PNS. They lead to a new classification, not based on clinical symptoms or oncological status but on the location of the targeted antigens. Three groups of autoantibodies can be delineated according to the neuronal localization of the targeted antigen: Group 1: cytoplasmic neuronal antigens (CNA) (anti-Hu, Yo, CV2/CRMP5, Ri, Ma1/2, Sox, Zic4). Group 2: cell-surface neuronal antigens (CSNA) (anti-NMDAR, Lgi1, CASPR2, VGCC, AMPAr, GlyR, DNER, GABABR, GABAAR, IgLONS, mGluR1 and mGluR5). Group 3: intracellular synaptic antigens (ISA) (anti-GAD65 and anti-amphiphysin). More than being solely a classification of patients, these three groups are related to profound differences in the pathophysiology and in the pathogenic role of the associated autoantibody. According to the type of associated autoantibody, the age and sex of patients, physicians are now able to predict the presence or absence of tumour, the clinical evolution and prognostic and also the response to immunomodulator treatments that differ fundamentally from one group to the others.
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Georgieva Z, Parton M. Cerebellar ataxia and epilepsy with anti-GAD antibodies: treatment with IVIG and plasmapheresis. BMJ Case Rep 2014; 2014:bcr-2013-202314. [PMID: 24419643 DOI: 10.1136/bcr-2013-202314] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Glutamic acid decarboxylase autoantibody (GAD-65) catalyses glutamate conversion into γ-aminobutyric acid (GABA) in the central nervous system and in the pancreatic β cells. Antibodies targeting GAD-65 are of uncertain pathogenic significance and occur in stiff person syndrome, cerebellar ataxia, epilepsy, limbic encephalitis and combinations thereof and diabetes mellitus. A 45-year-old man with a cerebellar gait ataxia, dysmetria, nystagmus and mild cerebellar dysarthria was diagnosed with insulin-dependent diabetes mellitus a year after the onset of neurological symptoms. He also developed complex and tonic-clonic seizures, resistant to anticonvulsant medication and deteriorated cognitively. Blood and cerebrospinal fluid serology, and imaging supported the diagnosis of GAD-65 cerebellar ataxia and epilepsy. He was treated with intravenous immunoglobulin and subsequently plasmapheresis. We report the outcome of 3 years of treatment, which resulted in the improvement of cerebellar signs (particularly gait), with some ultimate decline of efficacy.
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Viaccoz A, Honnorat J. Paraneoplastic neurological syndromes: general treatment overview. Curr Treat Options Neurol 2013; 15:150-68. [PMID: 23436113 DOI: 10.1007/s11940-013-0220-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OPINION STATEMENT Major recent discoveries have bringing out a revised definition of paraneoplastic neurological syndromes (PNS), bringing out the concept of antibody-mediated neurological disorders, triggered or not by cancer. Classification of these diseases is not based anymore on the clinical pattern or an underlying tumor, but on the location of the targeted antigens. Indeed, evolution, response to treatment, and pathophysiology are radically different according to the associated antibodies. In some patients with newly described antibodies targeting cell-surface antigens, humoral immunity seems to play a direct role and a dramatic improvement is observed with immunomodulator treatments. In these patients, an associated tumor is less frequent. Conversely, patients with antibodies directed against intracellular targets are, in most cases, characterized by a high degree of irreversible neuronal death mediated by cytotoxic T-cells and do not improve after immunomodulator treatments. In these patients, an associated tumor is highly frequent and must be cured as soon as possible. A third group of patients can be identified with anti-GAD65 and anti-Amphiphysin antibodies. In patients with these antibodies, the efficiency of immunomodulator treatments is less clear as well as the type of immune response that could be a mix between humoral and cellular. In this last group, the antigen is intracellular, but patients may improve with immunomodulator treatments and associated tumors are rare. Thus, identification of associated antibodies should be prompt and the treatment guided according the identified antibody. Mainstream of treatment include the quest of a tumor and its cure. Immunotherapy must be promptly initiated, targeting humoral, or cellular immune response, or both, according to the associated antibodies. Furthermore, in some situations such as Lambert-Eaton Myasthenic Syndromes and Stiff-Person Syndromes, symptomatic drugs can be useful to control the symptoms.
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Affiliation(s)
- Aurélien Viaccoz
- Neuro-Oncologie, Hôpital Neurologique Pierre Wertheimer, 59 Boulevard Pinel, 69677, Bron Cedex, France
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Mariani LL, Degos B, Honnorat J, Trouillas P, Rabin M, Koenig M, Anheim M. From anti-GAD to ataxia with ocular motor apraxia type 2: through the looking glass. J Neurol 2013; 260:1158-9. [PMID: 23370611 DOI: 10.1007/s00415-013-6840-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/08/2013] [Accepted: 01/11/2013] [Indexed: 11/28/2022]
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Nanri K, Niwa H, Mitoma H, Takei A, Ikeda J, Harada T, Okita M, Takeguchi M, Taguchi T, Mizusawa H. Low-Titer Anti-GAD-Antibody-Positive Cerebellar Ataxia. THE CEREBELLUM 2012; 12:171-5. [DOI: 10.1007/s12311-012-0411-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Rakocevic G, Floeter MK. Autoimmune stiff person syndrome and related myelopathies: understanding of electrophysiological and immunological processes. Muscle Nerve 2012; 45:623-34. [PMID: 22499087 DOI: 10.1002/mus.23234] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stiff person syndrome (SPS) is a disabling autoimmune central nervous system disorder characterized by progressive muscle rigidity and gait impairment with superimposed painful spasms that involve axial and limb musculature, triggered by heightened sensitivity to external stimuli. Impaired synaptic GABAergic inhibition resulting from intrathecal B-cell-mediated clonal synthesis of autoantibodies against various presynaptic and synaptic proteins in the inhibitory neurons of the brain and spinal cord is believed to be an underlying pathogenic mechanism. SPS is most often idiopathic, but it can occur as a paraneoplastic condition. Despite evidence that anti-GAD and related autoantibodies impair GABA synthesis, the exact pathogenic mechanism of SPS is not fully elucidated. The strong association with several MHC-II alleles and improvement of symptoms with immune-modulating therapies support an autoimmune etiology of SPS. In this review, we discuss the clinical spectrum, neurophysiological mechanisms, and therapeutic options, including a rationale for agents that modulate B-cell function in SPS.
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Affiliation(s)
- Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, Pennsylvania 19107, USA.
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Stiff person syndrome: advances in pathogenesis and therapeutic interventions. Curr Treat Options Neurol 2011; 11:102-10. [PMID: 19210912 DOI: 10.1007/s11940-009-0013-9] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Stiff person syndrome (SPS) varies from mild to severe, but if untreated it can be progressive and disabling. Although progress has been made in understanding and treating SPS, the disease remains underdiagnosed, delaying treatment. Antibodies against glutamic acid decarboxylase provide an excellent diagnostic marker, but their role in disease pathogenesis is uncertain. Research focused on identifying new autoantigens has provided evidence that gamma-aminobutyric acid (GABA)(A) receptor-associated protein (GABARAP), a 14-kD protein localized at the postsynaptic regions of GABAergic synapses, is an antigenic target. Circulating anti-GABARAP antibodies that inhibit GABA(A) receptor expression on GABAergic neurons have been found in up to 65% of SPS patients. The impairment of GABAergic pathways and reduction of brain GABA results in clinical manifestations of stiffness, spasms, and phobias. Increased awareness of SPS among practicing physicians is necessary to recognize the disease early and prevent permanent disability. Most patients with SPS respond to GABA-enhancing drugs, but the high doses required cause unacceptable adverse effects. The disease clearly responds to intravenous immunoglobulin, but repeated infusions are needed to maintain response. New immunomodulating agents are being explored to treat difficult cases and to induce long-lasting remissions.
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Awad A, Stüve O, Mayo M, Alkawadri R, Estephan B. Anti-glutamic Acid decarboxylase antibody-associated ataxia as an extrahepatic autoimmune manifestation of hepatitis C infection: a case report. Case Rep Neurol Med 2011; 2011:975152. [PMID: 22937348 PMCID: PMC3420584 DOI: 10.1155/2011/975152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/15/2011] [Indexed: 11/18/2022] Open
Abstract
Extrahepatic immunological manifestations of hepatitis C virus (HCV) are well described. In addition, antiglutamic acid decarboxylase (GAD) antibody-associated cerebellar ataxia is well-established entity. However, there have been no reports in the literature of anti-GAD antibody-associated ataxia as an extrahepatic manifestation of HCV infection. We report the case of a young woman with chronic hepatitis C virus and multiple extrahepatic autoimmune diseases including Sjögren syndrome and pernicious anemia who presented with subacute midline cerebellar syndrome and was found to have positive antiglutamic acid decarboxylase (GAD) antibody in the serum and cerebrospinal fluid. An extensive diagnostic workup to rule out neoplastic growths was negative, suggesting the diagnosis of nonparaneoplastic antiglutamic acid decarboxylase antibody-associated cerebellar ataxia as an additional extrahepatic manifestation of hepatitis C virus infection. The patient failed to respond to high-dose steroids and intravenous immunoglobulin. Treatment with the monoclonal antibody rituximab stabilized the disease. We postulate that anti-GAD associated ataxia could be an extrahepatic manifestation of HCV infection.
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Affiliation(s)
- Amer Awad
- Baton Rouge Neurology Associates, Baton Rouge General Medical Center, Baton Rouge, LA, USA
| | - Olaf Stüve
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Neurology Section, VA North Texas Health Care Systems, Dallas, TX, USA
| | - Marlyn Mayo
- Department of Internal Medicine-Digestive and Liver Diseases, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rafeed Alkawadri
- Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bachir Estephan
- Department of Neurology, University of Kansas Medical Center, Kansas, KS, USA
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Rizzi M, Knoth R, Hampe CS, Lorenz P, Gougeon ML, Lemercier B, Venhoff N, Ferrera F, Salzer U, Thiesen HJ, Peter HH, Walker UA, Eibel H. Long-lived plasma cells and memory B cells produce pathogenic anti-GAD65 autoantibodies in Stiff Person Syndrome. PLoS One 2010; 5:e10838. [PMID: 20520773 PMCID: PMC2877104 DOI: 10.1371/journal.pone.0010838] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 04/22/2010] [Indexed: 11/25/2022] Open
Abstract
Stiff person syndrome (SPS) is a rare, neurological disorder characterized by sudden cramps and spasms. High titers of enzyme-inhibiting IgG autoantibodies against the 65 kD isoform of glutamic acid decarboxylase (GAD65) are a hallmark of SPS, implicating an autoimmune component in the pathology of the syndrome. Studying the B cell compartment and the anti-GAD65 B cell response in two monozygotic twins suffering from SPS, who were treated with the B cell-depleting monoclonal anti-CD20 antibody rituximab, we found that the humoral autoimmune response in SPS is composed of a rituximab-sensitive part that is rapidly cleared after treatment, and a rituximab-resistant component, which persists and acts as a reservoir for autoantibodies inhibiting GAD65 enzyme activity. Our data show that these potentially pathogenic anti-GAD65 autoantibodies are secreted by long-lived plasma cells, which may either be persistent or develop from rituximab-resistant memory B lymphocytes. Both subsets represent only a fraction of anti-GAD65 autoantibody secreting cells. Therefore, the identification and targeting of this compartment is a key factor for successful treatment planning of SPS and of similar autoimmune diseases.
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Affiliation(s)
- Marta Rizzi
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
- Clinical Research Unit for Rheumatology, University Medical Center Freiburg, Freiburg, Germany
| | - Rolf Knoth
- Department of Neuropathology, Institute of Pathology, University Medical Center Freiburg, Freiburg, Germany
| | - Christiane S. Hampe
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Peter Lorenz
- Institute of Immunology, University of Rostock, Rostock, Germany
| | - Marie-Lise Gougeon
- Institut Pasteur, Antiviral Immunity, Biotherapy and Vaccine Unit, Paris, France
| | - Brigitte Lemercier
- Institut Pasteur, Antiviral Immunity, Biotherapy and Vaccine Unit, Paris, France
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Francesca Ferrera
- Centre of Excellence for Biomedical Research, University of Genova, Genova, Italy
| | - Ulrich Salzer
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | | | - Hans-Hartmut Peter
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Ulrich A. Walker
- Department of Rheumatology at Basel University, Basel, Switzerland
| | - Hermann Eibel
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
- Clinical Research Unit for Rheumatology, University Medical Center Freiburg, Freiburg, Germany
- * E-mail:
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Kobayakawa Y, Tateishi T, Kawamura N, Doi H, Ohyagi Y, Kira JI. [A case of immune-mediated encephalopathy showing refractory epilepsy and extensive brain MRI lesions associated with anti-glutamic acid decarboxylase antibody]. Rinsho Shinkeigaku 2010; 50:92-7. [PMID: 20196490 DOI: 10.5692/clinicalneurol.50.92] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We reported a patient with immune-mediated encephalopathy showing refractory epilepsy and multiple brain lesions on MRI. The patient had high titers of anti-glutamic acid decarboxylase (GAD) antibody in sera and cerebrospinal fluid (CSF). A 36-year-old previously healthy woman was admitted to our hospital with onset of sudden generalized seizure that then persisted for one month. She had repeated epileptic attacks accompanied with loss of consciousness, and was refractory to valproic acid, zonisamide (200 mg/day) and phenobarbital (200 mg/day). Brain MRI showed multiple hyperintense lesions in predominantly bilateral frontal lobes, parietal lobes, occipital lobes and cingulate cortices. EEG showed epileptic activities (frequent sharp waves) in bilateral frontal regions. After admission, attacks disappeared through the administration of clonazepam (1.5 mg/day), though the patient remained slightly disoriented. As titers of anti-GAD antibody in sera and CSF were extremely high, we implemented plasma exchanges. After treatment, titers of anti-GAD antibody in sera and CSF decreased. The patient completely recovered to an alert state and the abnormal MRI lesions almost disappeared. Since GAD catalyzes production of gamma-aminobutyric acid (GABA), it is proposed that anti-GAD antibodies reduce synthesis of GABA or interferes with exocytosis of GABA in the nervous system. Anti-GAD antibodies are detected in some rare neurological disorders such as stiff-person syndrome. Recently, anti-GAD antibodies have been reported as implicated in cerebellar ataxia, palatal myoclonus, refractory epilepsy and limbic encephalitis. Epilepsy associated with the anti-GAD antibody is mostly pharmacoresistant temporal lobe epilepsy; with brain MRI showing no abnormality or only hippocampal sclerosis. It is very rare that brain MRI shows extensive abnormal lesions except in the hippocampus. This case suggests that anti-GAD antibodies could contribute to unexplained encephalopathy with extensive brain MRI lesions and drug-resistant symptomatic epilepsy.
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Affiliation(s)
- Yuko Kobayakawa
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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Paquin Proulx D, Aubin E, Lemieux R, Bazin R. Inhibition of B cell-mediated antigen presentation by intravenous immunoglobulins (IVIg). Clin Immunol 2010; 135:422-9. [PMID: 20138586 DOI: 10.1016/j.clim.2010.01.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 12/16/2009] [Accepted: 01/06/2010] [Indexed: 12/01/2022]
Abstract
Previous work from our laboratory revealed that IVIg interacted with intracellular proteins involved in antigen presentation in B cells, suggesting that IVIg might interfere with the process of antigen presentation in these cells. In the present work, we used an in vitro assay with ovalbumin as model antigen and showed that IVIg inhibited both BCR-dependent and BCR-independent antigen presentation. The inhibition could not be explained by a modulation of expression of MHC II molecules expressed on B cells and was shown to occur in an FcgammaRIIb-independent manner, suggesting that the events responsible for the inhibitory effect occur at the intracellular level. This was supported by the observation of a direct correlation between the level of spontaneous internalization of two different proteins (IVIg and HSA) and their inhibitory potential. The inhibition of B cell-mediated antigen presentation reported here may help explain some of the anti-inflammatory effects of IVIg observed in treated patients, such as a decrease in autoantibody production.
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Indirect inhibition of in vivo and in vitro T-cell responses by intravenous immunoglobulins due to impaired antigen presentation. Blood 2009; 115:1727-34. [PMID: 19965673 DOI: 10.1182/blood-2009-06-225417] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Several clinical studies done with intravenous immunoglobulin (IVIg)-treated autoimmune patients as well as several in vitro studies have revealed that IVIg can reduce polyclonal T-cell activation and modify their cytokine secretion pattern. However, their effect on (auto)antigen-specific T-cell responses has never been addressed directly. In the present work, we used an in vivo model of induction of antigen-specific T-cell responses and an in vitro antigen presentation system to study the effects of IVIg on T-cell responses. The results obtained showed that IVIg inhibited both the in vivo and in vitro antigen-specific T-cell responses but that this effect was the indirect consequence of a reduction in the antigen presentation ability of antigen-presenting cells. The inhibitory effect of IVIg was FcgammaRIIb-independent, suggesting that IVIg must interfere with activating FcgammaRs expressed on antigen-presenting cells to reduce their ability to present antigens. Such inhibition of T-cell responses by reducing antigen presentation may therefore contribute to the well-known anti-inflammatory effects of IVIg in autoimmune diseases.
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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Abstract
BACKGROUND Paraneoplastic neurologic syndromes (PNS) constitute a rare group of disorders resulting from damage to the nervous system in the setting of cancer physically unrelated to the tumor site. PNS are believed to result from an autoimmune attack of normal neuronal tissue, spurred by similar neuronal antigens ectopically expressed by tumor cells. REVIEW SUMMARY The most common PNS are reviewed and also their association with specific onconeural antibodies, some directly pathogenic, others whose role in the disease process is less clear-cut. This diversity in pathogenesis is likely due to the relative role of humoral versus cellular immunity in PNS. Virtually any cancer may result in PNS but certain tumors, small cell lung cancer, gynecologic cancers (breast and ovarian), thymoma, and plasma cell tumors are more frequently encountered. In most instances, immunosuppressive therapy is unhelpful and outcome is poor. CONCLUSIONS PNS have diverse presentations, affecting both the central and peripheral nervous system and commonly, it is the PNS, not cancer that is the presenting symptom. Only subsequently, after onconeural antibodies are discovered or cancer is found, is PNS diagnosed. Neurologists should familiarize themselves with these rare syndromes and treatment principles, as rapid detection and treatment of the underlying tumor offer the best chance for recovery or prevention of further neurologic deterioration.
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Affiliation(s)
- Thomas B Toothaker
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10021, USA.
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Vulliemoz S, Vanini G, Truffert A, Chizzolini C, Seeck M. Epilepsy and cerebellar ataxia associated with anti-glutamic acid decarboxylase antibodies. BMJ Case Rep 2009; 2009:bcr09.2008.0977. [PMID: 21686528 DOI: 10.1136/bcr.09.2008.0977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Anti-glutamic acid decarboxylase (GAD) antibodies are described in stiff-person syndrome and also in other neurological syndromes, including cerebellar ataxia and epilepsy. This paper reports the case of a patient who had chronic focal epilepsy, upbeat nystagmus and cerebellar ataxia, associated with a polyautoimmune response including anti-GAD antibodies. Both gait and nystagmus improved markedly after immunosuppressive treatment with corticosteroids and azathioprine. After the introduction of benzodiazepines, previously refractory seizures were completely controlled. Anti-GAD antibodies should be actively sought out in pharmacoresistant epilepsy, particularly if other neurological abnormalities are present. Combined treatment with immunosuppressants and γhydroxybutyric acidergic agents may be highly effective.
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Affiliation(s)
- S Vulliemoz
- University Hospital, rue Micheli-du Crest 24, Geneva, 1211, Switzerland
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Nanri K, Okita M, Takeguchi M, Taguchi T, Ishiko T, Saito H, Otsuka T, Mitoma H, Koizumi K. Intravenous immunoglobulin therapy for autoantibody-positive cerebellar ataxia. Intern Med 2009; 48:783-90. [PMID: 19443972 DOI: 10.2169/internalmedicine.48.1802] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE It has been reported that autoimmune cerebellar ataxias, such as anti-glutamic acid decarboxylase (GAD)-antibody-positive cerebellar ataxia and gluten ataxia, are treatable. Here, we examined the therapeutic efficacy of intravenous immunoglobulin (IVIg) on autoantibody-positive cerebellar ataxia. PATIENTS AND METHODS IVIg therapy was administered in seven autoantibody-positive cerebellar ataxia patients. Therapeutic efficacy was examined in terms of its effects on clinical symptoms and changes in brain perfusion using single photon emission computed tomography (SPECT). RESULTS Treatment was effective in four cerebellar cortical atrophy patients (two anti-GAD antibody-positive and two anti-gliadin antibody-positive) and in one anti-thyroid antibody-positive spinocerebellar ataxia type 3 (SCA3) patient, but not in two multiple system atrophy (MSA) patients. All four IVIg effective patients who underwent SPECT showed apparent increases in cerebellar perfusion. CONCLUSION If cerebellar ataxia with an autoimmune mechanism is suspected and radiological findings do not reveal MSA, it is worth considering immunotherapy including IVIg.
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Affiliation(s)
- Kazunori Nanri
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Tokyo.
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Glutamic acid decarboxylase (GAD) antibodies in tardive dyskinesia (TD) as compared to patients with schizophrenia without TD and normal controls. Schizophr Res 2008; 105:287-8. [PMID: 18710797 DOI: 10.1016/j.schres.2008.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 06/16/2008] [Accepted: 06/18/2008] [Indexed: 11/22/2022]
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Marnane M, Vincent A, Hutchinson M. New-onset focal epilepsy with palatal tremor and glutamic acid decarboxylase antibodies responding to intravenous immunoglobulin. J Neurol 2008; 255:1603-4. [PMID: 18758886 DOI: 10.1007/s00415-008-0986-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/23/2008] [Accepted: 04/24/2008] [Indexed: 11/27/2022]
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Bayreuther C, Hieronimus S, Ferrari P, Thomas P, Lebrun C. Auto-immune cerebellar ataxia with anti-GAD antibodies accompanied by de novo late-onset type 1 diabetes mellitus. DIABETES & METABOLISM 2008; 34:386-8. [PMID: 18583169 DOI: 10.1016/j.diabet.2008.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 01/29/2008] [Accepted: 02/24/2008] [Indexed: 11/26/2022]
Abstract
UNLABELLED Autoantibodies to glutamic acid decarboxylase (GAD-Ab) have been described in stiff-man syndrome, type 1 diabetes mellitus and in patients with auto-immune polyglandular failure. In addition, a few patients with progressive cerebellar ataxia show high titres of GAD-Ab, suggesting an auto-immune origin. AIM This is a report of a patient presenting with cerebellar ataxia associated to late-onset type 1 diabetes and polyendocrine auto-immunity. CASE REPORT A 47-year-old woman with a past medical history of vitiligo and Graves' disease presented with late-onset type 1 diabetes. For two years, she had complained of progressive gait instability and oscillopsia. Neurological examination revealed multidirectional, horizontal rotatory fixation and gaze nystagmus, gait ataxia and mild limb ataxia in the left upper arm. METHODS Imaging studies, electrophysiological studies, routine biological and detailed immunological screening as well as a study of cerebrospinal fluid (CSF) were performed. RESULTS Brain magnetic resonance imaging showed cerebellar atrophy. Routine biological screening was normal. Immunological screening showed positivity for numerous antibodies (Ab), including GAD-Ab, thyroid peroxidase-Ab, thyroglobulin-Ab, 21-hydroxylase (adrenal)-Ab, gastric parietal cell-Ab and GM1 ganglioside IgG-Ab. CSF was normal, with no oligoclonal bands detected. GAD-Ab were positive in CSF, suggesting an auto-immune origin of the cerebellar ataxia. Treatment with intravenous immunoglobulin led to a slight improvement in nystagmus and gait instability. CONCLUSION Auto-immune cerebellar ataxia related to GAD-Ab is a rare condition that typically affects women with late-onset type 1 diabetes or other auto-immune disorders, including auto-immune polyendocrinopathy. Immunomodulatory treatment may be effective.
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Affiliation(s)
- C Bayreuther
- Neurology Department, Pasteur Hospital, 30, voie Romaine, 06002 Nice, France.
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Advances in the pathogenesis and treatment of patients with stiff person syndrome. Curr Neurol Neurosci Rep 2008; 8:48-55. [PMID: 18367039 DOI: 10.1007/s11910-008-0009-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Advances in the clinical diagnosis, prognosis, pathogenesis, and therapies for stiff person syndrome (SPS), based on observations in more than 50 consecutive patients, are presented. The syndrome varies from mild to severe, but if untreated it can be progressive and disabling. SPS remains a largely underdiagnosed condition. Anti-glutamic acid decarboxylase (GAD) antibodies provide an excellent diagnostic marker, but their role in disease pathogenesis is uncertain. Research focused on identifying new autoantigens has provided evidence that gamma-aminobutyric acid (GABA)(A) receptor-associated protein (GABARAP), a 14-kD protein localized at the postsynaptic regions of GABAergic synapses, is a new antigenic target. In up to 65% of SPS patients, there are circulating anti-GABARAP antibodies that inhibit the GABA(A) receptor expression on GABAergic neurons. This review examines the diagnostic criteria for SPS, SPS variants, common errors in diagnosis, and a step-by-step therapeutic approach, including new advances in therapy.
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Bonnan M, Cabre P, Olindo S, Signate A, Saint-Vil M, Smadja D. [Steroid treatment in four cases of anti-GAD cerebellar ataxia]. Rev Neurol (Paris) 2008; 164:427-33. [PMID: 18555874 DOI: 10.1016/j.neurol.2008.02.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2007] [Revised: 12/09/2007] [Accepted: 02/08/2008] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Few neurological diseases are linked with anti-glutamic acid decarboxylase antibodies (GAD-ab); stiff man syndrome is an example. Cerebellar ataxia is a new feature of this expanding spectrum. No therapeutic trial is yet available in these diseases. We here report on four patients suffering from cerebellar ataxia linked with GAD-ab and review the data in the literature on this recently described syndrome. METHOD We conducted an open trial with monthly pulsed steroids. Steroid pulses were given six months followed with placebo for another six months. Main clinical and biological parameters were monitored monthly (International Cooperative Cerebellar Ataxia Rating Scale [ICARS] and GAD-ab). RESULT The clinical response was found limited and inconstant. Transient decline in GAD-ab level was noted in two patients. Moreover, GAD-ab level was found highly variable and did not correlate with clinical parameters. DISCUSSION Cerebellar ataxia with GAD-ab is an increasingly described syndrome. Outcome can be severe, leading to definitive cerebellar atrophy. Diagnosis is supported by high level of serum GAD-ab with intrathecal secretion. Experimental data have suggested a direct excitotoxic effect of GAD-ab on Purkinje cells. Response to various treatments is often disappointing. Improvement has been obtained with veinoglobulins in individual patients. A weak clinical and biological response was associated with monthly steroid pulses.
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Affiliation(s)
- M Bonnan
- Service de neurologie, hôpital Pierre-Zobda-Quitman, centre hospitalier universitaire de Fort-de-France, B.P. 632, 97261 Fort-de-France cedex, France.
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Hall TR, Bogdani M, Leboeuf RC, Kirk EA, Maziarz M, Banga JP, Oak S, Pennington CA, Hampe CS. Modulation of diabetes in NOD mice by GAD65-specific monoclonal antibodies is epitope specific and accompanied by anti-idiotypic antibodies. Immunology 2007; 123:547-54. [PMID: 18005036 DOI: 10.1111/j.1365-2567.2007.02724.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Type 1 diabetes is caused by the autoimmune destruction of pancreatic beta cells. Here we show that administration of a human monoclonal antibody (b96.11) specific to the 65-kDa isoform of glutamate decarboxylase (GAD65) to prediabetic non-obese diabetic (NOD) mice significantly delays the onset of autoimmune diabetes. We found this effect to be epitope-specific, as only b96.11 showed this therapeutic property, while a GAD65-specific human monoclonal control antibody (b78) derived from the same patient, but specific to a different determinant of GAD65, had no significant effect on the progression of disease. Administration of b96.11 or b78 to NOD mice was accompanied by the generation of anti-idiotypic antibodies. Importantly, the induced anti-idiotypic antibodies were specific for the immunizing antibody and blocked the binding of GAD65 by the respective antibody. These findings suggest a potential role for the internal image of the GAD65 determinant recognized by b96.11 in the anti-idiotypic antibody, supporting an immunomodulatory role for GAD65-specific autoantibodies, as originally postulated by Jerne.
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Affiliation(s)
- Tyler R Hall
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
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Essalmi L, Meaux-Ruault N, Hafsaoui C, Gil H, Curlier E, Dupond JL. Syndrome de la personne raide associé à un thymome: efficacité de la thymectomie. Rev Med Interne 2007; 28:627-30. [PMID: 17624641 DOI: 10.1016/j.revmed.2007.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 05/04/2007] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Stiff person syndrome is a rare autoimmune neurologic disorder characterized by axial muscular rigidity and intermittent painful spasms. Three distinct forms are described: auto-immune, paraneoplastic and idiopathic. EXEGESIS We report the case of a 51-year-old man with an history of Stiff Person Syndrome with typical clinical, electrophysiological and immunological findings. Anti-glutamic acid decarboxylase antibodies were present, as well as anti-amphiphysin antibodies, commonly reported in the paraneoplastic syndrome. CT scan revealed a thymoma. Surgical resection was followed by reduction of the neurologic symptoms, without lowering the auto antibodies titer. CONCLUSIONS The association between Stiff Person Syndrome and thymoma is exceptional. Thymectomy is an effective treatment and may act without change of the autoantibodies titer. Patients with Stiff Person Syndrome should be systematically tested for thymoma.
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Affiliation(s)
- L Essalmi
- Service de médecine interne et immunologie clinique, hôpital Jean-Minjoz, CHU de Besançon, 2, boulevard Fleming, 25030 Besançon cedex, France
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Espay AJ, Chen R. Rigidity and spasms from autoimmune encephalomyelopathies: stiff-person syndrome. Muscle Nerve 2007; 34:677-90. [PMID: 16969837 DOI: 10.1002/mus.20653] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stiff-person syndrome (SPS) is a disorder characterized by progressive muscle rigidity with superimposed painful muscle spasms and gait impairment due to continuous motor activity. Evidence has accumulated in favor of SPS representing an autoimmune, predominantly encephalomyelopathic disorder resulting from B-cell-mediated clonal production of autoantibodies against presynaptic inhibitory epitopes on the enzyme glutamic acid decarboxylase (GAD) and the synaptic membrane protein amphiphysin. Recognition of the clinical spectrum of SPS is important, particularly the upper-limb, cervical, and cranial nerve involvement that occurs in paraneoplastic variants. The correlation between antibody levels and severity of disease offers evidence for a pathogenic role for the anti-GAD and anti-amphiphysin autoantibodies. The scarcity of neuropathological correlates stand in sharp contrast with the severity of the disability in affected individuals and suggests that functional impairment of inhibitory circuits without structural damage is sufficient to develop the full clinical spectrum of SPS. The rarity of this condition limits the feasibility of controlled clinical trials in the treatment of SPS, but the available evidence suggest that drugs that increase cortical and spinal inhibition such as benzodiazepines and drugs that provide immune modulation such as intravenous immunoglobulin, plasmapheresis, and prednisone are effective treatments.
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Affiliation(s)
- Alberto J Espay
- Department of Neurology, Neuroscience Institute, Movement Disorders Center, University of Cincinnati, Cincinnati, Ohio, USA
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