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Shang P, Zhang HL. Comment on "Distribution characteristics of antinuclear antibodies in Guillain-Barré syndrome and its relationship with disease severity". Clin Neurol Neurosurg 2024; 245:108496. [PMID: 39137582 DOI: 10.1016/j.clineuro.2024.108496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 08/03/2024] [Indexed: 08/15/2024]
Affiliation(s)
- Pei Shang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester USA.
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, China.
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Xu L, Zhou J, Zhang Y, Wang Y, Yan X, Wang L, Tang X, Luo C. A single-centre study on abnormal antinuclear antibodies in children caused by intravenous infusion of gamma globulin. Front Immunol 2024; 15:1410661. [PMID: 39091491 PMCID: PMC11291197 DOI: 10.3389/fimmu.2024.1410661] [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: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 08/04/2024] Open
Abstract
Objective To clarify the impact of intravenous infusion of gamma globulin (IVIg) on antinuclear antibodies (ANAs) in children. Methods A retrospective analysis was performed on the data of children with nonspecific autoantibody-related diseases whose antinuclear antibody (ANA) and autoantibody profiles were detected in our hospital from January to March 2022. A total of 108 patients with a clear history of IVIg infusion within 28 days composed the IVIg group, and 1201 patients without a history of IVIg infusion composed the non-IVIg group. Results All patients in the IVIg group had either positive ANAs or positive autoantibodies. Anti-SSA, anti-Ro52 and anti-AMA Mi2 were the top three autoantibodies in the IVIg group. The proportions of patients who were positive for either of these three autoantibodies in the IVIg group were significantly greater than those in the non-IVIg group (all P<0.5). Spearman correlation analysis revealed that the signal intensities of anti-SSA and anti-Ro52 were negatively correlated with the number of days of ANA detection after IVIg infusion (P<0.05). Multiple logistic analyses revealed that a greater total dosage of IVIg, greater IVIg per kilogram of body weight, and fewer ANA detection days after IVIg infusion were independent risk factors for positive anti-SSA and anti-Ro52 results. Conclusions It is recommended that if rheumatic diseases are suspected, ANA detection should be carried out beforeIVIg infusion. But for patients who are positive for at least one of these three autoantibodies after IVIg infusion, doctors should first consider adoptive antibodies.
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Affiliation(s)
- Li Xu
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Juan Zhou
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Yu Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Yating Wang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Xin Yan
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Li Wang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Chong Luo
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
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Miyamoto T, Fukunaga Y, Munakata A, Murai K. Antibodies against glutamic acid decarboxylase in intravenous immunoglobulin preparations can affect the diagnosis of type 1 diabetes mellitus. Vox Sang 2024. [PMID: 38955431 DOI: 10.1111/vox.13710] [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: 04/28/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND OBJECTIVES Intravenous immunoglobulins (IVIgs) contain various autoantibodies, including those against glutamic acid decarboxylase (GADAb), a valuable biomarker of type 1 diabetes mellitus. Passive transfer of GADAb from IVIgs to patients poses a risk of misdiagnosis, and information on the specific titres of GADAb and their impact on diagnostic accuracy remains limited. This study aimed to provide further insights into the origin of GADAb detected in patient serum following IVIg infusion. MATERIALS AND METHODS GADAb titres in IVIg products from Japan and the United States were measured using enzyme-linked immunosorbent assay-based assays. For reliable quantification, GADAb titres in pooled plasma were quantified and compared with those in the IVIg products. The determined titres were used to estimate the likelihood of passively detecting acquired GADAb in individuals receiving IVIgs. RESULTS GADAbs were prevalent in IVIg products; however, the titres varied significantly among different lots and products. Importantly, IVIg-derived GADAb was estimated to remain detectable in patient serum for up to 100 days following a dosage of 2000 mg/kg. CONCLUSION Clinicians should consider that IVIg preparations may contain GADAb, which can lead to false-positive results in serological assays. Careful interpretation of the assay results is key to the definitive diagnosis of type 1 diabetes mellitus.
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Affiliation(s)
- Tatsuki Miyamoto
- Research and Development Division, Japan Blood Products Organization, Kobe, Hyogo, Japan
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
| | - Yuki Fukunaga
- Research and Development Division, Japan Blood Products Organization, Kobe, Hyogo, Japan
| | - Ai Munakata
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
| | - Katsushi Murai
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
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Redenbaugh V, Fryer JP, Cacciaguerra L, Chen JJ, Greenwood TM, Gilligan M, Thakolwiboon S, Majed M, Chia NH, McKeon A, Mills JR, Lopez Chiriboga AS, Tillema JM, Yang B, Abdulrahman Y, Guo K, Vorasoot N, Sanchez CV, Tajfirouz DA, Toledano M, Zekeridou A, Dubey D, Gombolay GY, Caparó-Zamalloa C, Kister I, Pittock SJ, Flanagan EP. Diagnostic Utility of MOG Antibody Testing in Cerebrospinal Fluid. Ann Neurol 2024; 96:34-45. [PMID: 38591875 PMCID: PMC11186718 DOI: 10.1002/ana.26931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/09/2024] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVE The aim of this study was to assess the diagnostic utility of cerebrospinal fluid (CSF) myelin oligodendrocyte glycoprotein antibodies (MOG-IgG) testing. METHODS We retrospectively identified patients for CSF MOG-IgG testing from January 1, 1996, to May 1, 2023, at Mayo Clinic and other medical centers that sent CSF MOG-IgG for testing including: controls, 282; serum MOG-IgG positive MOG antibody-associated disease (MOGAD), 74; serum MOG-IgG negative high-risk phenotypes, 73; serum false positive MOG-IgG with alternative diagnoses, 18. A live cell-based assay assessed CSF MOG-IgG positivity (IgG-binding-index [IBI], ≥2.5) using multiple anti-human secondary antibodies and end-titers were calculated if sufficient sample volume. Correlation of CSF MOG-IgG IBI and titer was assessed. RESULTS The pan-IgG Fc-specific secondary was optimal, yielding CSF MOG-IgG sensitivity of 90% and specificity of 98% (Youden's index 0.88). CSF MOG-IgG was positive in: 4/282 (1.4%) controls; 66/74 (89%) serum MOG-IgG positive MOGAD patients; and 9/73 (12%) serum MOG-IgG negative patients with high-risk phenotypes. Serum negative but CSF positive MOG-IgG accounted for 9/83 (11%) MOGAD patients, and all fulfilled 2023 MOGAD diagnostic criteria. Subgroup analysis of serum MOG-IgG low-positives revealed CSF MOG-IgG positivity more in MOGAD (13/16[81%]) than other diseases with false positive serum MOG-IgG (3/15[20%]) (p = 0.01). CSF MOG-IgG IBI and CSF MOG-IgG titer (both available in 29 samples) were correlated (Spearman's r = 0.64, p < 0.001). INTERPRETATION CSF MOG-IgG testing has diagnostic utility in patients with a suspicious phenotype but negative serum MOG-IgG, and those with low positive serum MOG-IgG results and diagnostic uncertainty. These findings support a role for CSF MOG-IgG testing in the appropriate clinical setting. ANN NEUROL 2024;96:34-45.
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Affiliation(s)
- Vyanka Redenbaugh
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - James P. Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Laura Cacciaguerra
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John J. Chen
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Tammy M. Greenwood
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael Gilligan
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Neurology, St Vincent’s University Hospital, Dublin, Ireland
| | - Smathorn Thakolwiboon
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Masoud Majed
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Nicholas H Chia
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John R. Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Jan-Mendelt Tillema
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Binxia Yang
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Yahya Abdulrahman
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Kai Guo
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Nisa Vorasoot
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Deena A. Tajfirouz
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michel Toledano
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Anastasia Zekeridou
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Divyanshu Dubey
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Grace Y Gombolay
- Emory University, Children’s Healthcare of Atlanta: Pediatrics Institute, USA
| | - César Caparó-Zamalloa
- Basic Research Center in Dementia and Central Nervous System Demyelinating Diseases, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Ilya Kister
- Department of Neurology, Comprehensive MS Center, NYU Grossman School of Medicine, New York, USA
| | - Sean J. Pittock
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eoin P. Flanagan
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Gilligan M, McGuigan C, McKeon A. Autoimmune central nervous system disorders: Antibody testing and its clinical utility. Clin Biochem 2024; 126:110746. [PMID: 38462203 PMCID: PMC11016295 DOI: 10.1016/j.clinbiochem.2024.110746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
A rapidly expanding repertoire of neural antibody biomarkers exists for autoimmune central nervous system (CNS) disorders. Following clinical recognition of an autoimmune CNS disorder, the detection of a neural antibody facilitates diagnosis and informs prognosis and management. This review considers the phenotypes, diagnostic assay methodologies, and clinical utility of neural antibodies in autoimmune CNS disorders. Autoimmune CNS disorders may present with a diverse range of clinical features. Clinical phenotype should inform the neural antibodies selected for testing via the use of phenotype-specific panels. Both serum and cerebrospinal fluid (CSF) are preferred in the vast majority of cases but for some analytes either CSF (e.g. N-methyl-D-aspartate receptor [NMDA-R] IgG) or serum (e.g. aquaporin-4 [AQP4] IgG) specimens may be preferred. Screening using 2 methods is recommended for most analytes, particularly paraneoplastic antibodies. We utilize murine tissue-based indirect immunofluorescence assay (TIFA) with subsequent confirmatory protein-specific testing. The cellular location of the target antigen informs choice of confirmatory diagnostic assay (e.g. blot for intracellular antigens such as Hu; cell-based assay for cell surface targets such as leucine-rich glioma inactivated 1 [LGI1]). Titers of positive results have limited diagnostic utility with the exception of glutamic acid decarboxylase (GAD) 65 IgG autoimmunity, which is associated with neurological disease at higher values. While novel antibodies are typically discovered using established techniques such as TIFA and immunoprecipitation-mass spectrometry, more recent high-throughput molecular technologies (such as protein microarray and phage-display immunoprecipitation sequencing) may expedite the process of antibody discovery. Individual neural antibodies inform the clinician regarding the clinical associations, oncological risk stratification and tumor histology, the likely prognosis, and immunotherapy choice. In the era of neural antibody biomarkers for autoimmune CNS disorders, access to appropriate laboratory assays for neural antibodies is of critical importance in the diagnosis and management of these disorders.
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Affiliation(s)
- Michael Gilligan
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Miyamoto T, Fukunaga Y, Ogasawara A, Munakata A, Murai K. Autoantibody profiles in intravenous immunoglobulin preparations: A possible cause of mistaken autoimmunity diagnosis. Transfusion 2024; 64:597-605. [PMID: 38400628 DOI: 10.1111/trf.17766] [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: 11/28/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Intravenous immunoglobulins (IVIgs) derived from the pooled plasma of thousands of donors contain numerous types of IgG molecules, including autoantibodies commonly used to diagnose autoimmunity. While these autoantibodies can cause misinterpretation of serological tests for IVIg recipients, their profiles in IVIg preparations are not fully understood. STUDY DESIGN AND METHODS Using binding-capability based immune assays, we measured 18 varieties of clinically relevant autoantibodies in domestic blood donor-derived IVIg products. In addition, we analyzed an IVIg product from a US brand to evaluate the influence of regional and racial differences. Based on the determined autoantibody titers, pharmacokinetics of passively acquired autoantibodies and their possible detection period in serum were estimated. RESULTS Anti-thyroglobulin (Tg), anti-thyroidperoxidase (TPO), and anti-Sjögren's-syndrome-related antigen A (SS-A) antibodies were present in considerable amounts in IVIg products. Notably, these three autoantibodies can be detected in IVIg recipients' sera for up to 3 months after infusion. DISCUSSION To the best of our knowledge, this is the first study that analyzed multiple autoantibody profiles in both pooled plasma and IVIg products and that further evaluated their potential influences on diagnosis of autoimmunity. Clinicians should keep in mind that IVIgs contain several autoantibodies and that their infusion can produce false-positive serology results. To establish an accurate diagnosis, serological tests must be carefully interpreted and clinical symptoms should be more purposefully considered if patients are receiving IVIg therapy.
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Affiliation(s)
- Tatsuki Miyamoto
- Research and Development Division, Japan Blood Products Organization, Kobe, Hyogo, Japan
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
| | - Yuki Fukunaga
- Research and Development Division, Japan Blood Products Organization, Kobe, Hyogo, Japan
| | - Atsushi Ogasawara
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
| | - Ai Munakata
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
| | - Katsushi Murai
- Pharmacovigilance Division, Japan Blood Products Organization, Minato-ku, Tokyo, Japan
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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Marquez D, Romero R, Klavansky D, Reynolds AS. HSV Encephalomyelitis in an Immunocompetent Patient With Prior Splenectomy. Neurohospitalist 2023; 13:312-316. [PMID: 37441208 PMCID: PMC10334047 DOI: 10.1177/19418744231169406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
A 44-year-old male with history of asplenia, provoked PE, and hyperlipidemia presented with ascending paralysis, bowel and bladder incontinence and altered mental status, and progressively developed acute hypoxic respiratory failure. Initial workup including CT head, magnetic resonance imaging (MRI) brain, and lumbar puncture which was concerning for herpes simplex virus (HSV) meningoencephalitis; out of caution he was started on multiple antibiotics consequently resulting in the development of Clostridium difficile (C.diff). He also received two doses of IVIG. He was transferred to our institution and after interval re-imaging via MRI brain and spinal surveys and repeat lumbar punctures, he was found to have a high CSF HSV titer and positive GAD 65 antibody, the latter likely a false positive due to IVIG administration. IVIG was not continued from the outside hospital due to the development of deep vein thrombosis (DVT), and the risks of plasmapheresis outweighed the benefits. The patient gradually improved after a prolonged course of acyclovir and was downgraded out of the Neuroscience ICU (NSICU), however decompensated due to rectal bleeding, and subsequently went into cardiac arrest. Though this patient underwent a splenectomy, his relative immunocompetency towards non-encapsulated organisms should have been preserved. It has not been clearly described in the literature how and why HSV encephalomyelitis takes a fulminant course in immunocompetent patients, including our asplenic patient. Furthermore, definitive treatment and management of this condition remains unclear. Severity of HSV encephalomyelitis has not been clearly described in the literature, particularly in immunocompetent patients (such as this asplenic patient).
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Affiliation(s)
- Destiny Marquez
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raquel Romero
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dana Klavansky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexandra S. Reynolds
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jarius S, Aktas O, Ayzenberg I, Bellmann-Strobl J, Berthele A, Giglhuber K, Häußler V, Havla J, Hellwig K, Hümmert MW, Kleiter I, Klotz L, Krumbholz M, Kümpfel T, Paul F, Ringelstein M, Ruprecht K, Senel M, Stellmann JP, Bergh FT, Tumani H, Wildemann B, Trebst C. Update on the diagnosis and treatment of neuromyelits optica spectrum disorders (NMOSD) - revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part I: Diagnosis and differential diagnosis. J Neurol 2023:10.1007/s00415-023-11634-0. [PMID: 37022481 DOI: 10.1007/s00415-023-11634-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 04/07/2023]
Abstract
The term 'neuromyelitis optica spectrum disorders' (NMOSD) is used as an umbrella term that refers to aquaporin-4 immunoglobulin G (AQP4-IgG)-positive neuromyelitis optica (NMO) and its formes frustes and to a number of closely related clinical syndromes without AQP4-IgG. NMOSD were originally considered subvariants of multiple sclerosis (MS) but are now widely recognized as disorders in their own right that are distinct from MS with regard to immunopathogenesis, clinical presentation, optimum treatment, and prognosis. In part 1 of this two-part article series, which ties in with our 2014 recommendations, the neuromyelitis optica study group (NEMOS) gives updated recommendations on the diagnosis and differential diagnosis of NMOSD. A key focus is on differentiating NMOSD from MS and from myelin oligodendrocyte glycoprotein antibody-associated encephalomyelitis (MOG-EM; also termed MOG antibody-associated disease, MOGAD), which shares significant similarity with NMOSD with regard to clinical and, partly, radiological presentation, but is a pathogenetically distinct disease. In part 2, we provide updated recommendations on the treatment of NMOSD, covering all newly approved drugs as well as established treatment options.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Katrin Giglhuber
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Vivien Häußler
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Markus Krumbholz
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Neurology and Stroke, University Hospital of Tübingen, Tübingen, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Friedemann Paul
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- APHM, Hopital de la Timone, CEMEREM, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | | | | | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany.
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Fnu Z, Uddin A, Navetta-Modrov B, Patnaik A, Kaell A. Inpatient Rheumatology Consultation Prompted by Positive Autoantibodies in Patients Receiving Intravenous Immunoglobulin Therapy: A Case Series and Literature Review. Cureus 2023; 15:e37008. [PMID: 37020710 PMCID: PMC10069874 DOI: 10.7759/cureus.37008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Intravenous immunoglobulin (IVIG) is a therapeutic preparation used in the treatment of multiple diseases. Autoimmune testing with antinuclear antibody (ANA) screening is often obtained for some of these conditions, but only after initiation of IVIG treatment. This can present a diagnostic dilemma in hospitalized patients and may trigger a rheumatology consultation. We describe our consultative inpatient two-year experience with five such patients and review the pertinent literature. A retrospective chart review of rheumatology inpatient consultations between 6-2018 and 6-2020 at our academic tertiary care hospital for post-IVIG positive serologies was performed. A pertinent literature review was performed. Five patients had a positive ANA and other autoantibodies detected in their serum after they received IVIG for non-rheumatological conditions. None of these patients met the criteria for a connective tissue disease. The literature review identified a total of 58 patients from case reports and case series, several of whom tested positive for ANA and other antibodies after receiving IVIG. Studies assessing specific IVIG products detected multiple autoantibodies in the donor pool. Autoimmune testing is initiated on inpatients receiving IVIG for non-rheumatological conditions. If an autoantibody ANA screen is positive, a rheumatology consultation may be requested. In the absence of pre-IVIG antibody tests it is difficult to interpret post-IVIG-positive antibodies. Whether such positive antibodies are of clinicopathological significance is determined by clinical judgment and time.
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Ali H, Buechler CR, Sanaullah O, Lucas A, Lohr KL. Iatrogenic ANA: An emerging source of expensive diagnostic confusion. Lupus 2023; 32:299-300. [PMID: 36473694 DOI: 10.1177/09612033221144600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intravenous immune globulin (IVIg) therapy has been shown to be useful in a multitude of disorders. IVIg is produced from pooled human plasma; therefore, autoantibodies found in the general population are also present in IVIg and transferred to those being transfused. This can prove a particular hazard for screening and diagnostic tests based on autoantibodies. We present a patient who was found to have a positive antinuclear antibody (ANA) titer after multiple IVIg transfusions, resulting in diagnostic confusion and unnecessary workup. A 45-year-old gentleman was diagnosed with atypical CIDP, initiated on a course of IVIg, and sent for inpatient rehabilitation. However, recovery was complicated by multiple readmissions for recurrent weakness, and as part of the workup for other etiologies, an ANA was found to be positive. Sub-serologies and paraneoplastic autoantibody panel were negative. In the absence of clinical symptoms, we recommended continued monitoring and repeat ANA testing 6 months after the last dose of IVIg; as any drug needs 5 half-lives to be eliminated from the body. Clinicians should consider any recent IVIg treatments when evaluating the pre-test probability of detecting an underlying connective tissue disease with ANA screening. Indiscriminate ANA levels in patients recently given IVIg lead to unnecessary and expensive further testing and consultation.
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Affiliation(s)
- Hammad Ali
- Department of Rheumatology, Division of Internal Medicine, 4530University of Kentucky, Lexington, KY, USA
| | - Connor R Buechler
- Department of Medicine and Dermatology, 144447University of Minnesota, Minneapolis, MN, USA
| | - Oneeb Sanaullah
- Department of Medicine, 23128Robert Packer Hospital, Geisinger University, Sayre, PA, USA
| | - Alexandria Lucas
- College of Medicine, 12252University of Kentucky, Lexington, KY, USA
| | - Kristine L Lohr
- Department of Rheumatology, Division of Internal Medicine, 4530University of Kentucky, Lexington, KY, USA
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12
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Davies AJ, Lleixà C, Siles AM, Gourlay DS, Berridge G, Dejnirattisai W, Ramírez-Santana C, Anaya JM, Falconar AK, Romero-Vivas CM, Osorio L, Parra B, Screaton GR, Mongkolsapaya J, Fischer R, Pardo CA, Halstead SK, Willison HJ, Querol L, Rinaldi S. Guillain-Barré Syndrome Following Zika Virus Infection Is Associated With a Diverse Spectrum of Peripheral Nerve Reactive Antibodies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 10:10/1/e200047. [PMID: 36411078 PMCID: PMC9679884 DOI: 10.1212/nxi.0000000000200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/01/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent outbreaks of Zika virus (ZIKV) in South and Central America have highlighted significant neurologic side effects. Concurrence with the inflammatory neuropathy Guillain-Barré syndrome (GBS) is observed in 1:4,000 ZIKV cases. Whether the neurologic symptoms of ZIKV infection are immune mediated is unclear. We used rodent and human live cellular models to screen for anti-peripheral nerve reactive IgG and IgM autoantibodies in the sera of patients with ZIKV with and without GBS. METHODS In this study, 52 patients with ZIKV-GBS were compared with 134 ZIKV-infected patients without GBS and 91 non-ZIKV controls. Positive sera were taken forward for target identification by immunoprecipitation and mass spectrometry, and candidate antigens were validated by ELISA and cell-based assays. Autoantibody reactions against glycolipid antigens were also screened on an array. RESULTS Overall, IgG antibody reactivities to rat Schwann cells (SCs) (6.5%) and myelinated cocultures (9.6%) were significantly higher, albeit infrequent, in the ZIKV-GBS group compared with all controls. IgM antibody immunoreactivity to dorsal root ganglia neurones (32.3%) and SCs (19.4%) was more frequently observed in the ZIKV-GBS group compared with other controls, whereas IgM reactivity to cocultures was as common in ZIKV and non-ZIKV sera. Strong axonal-binding ZIKV-GBS serum IgG antibodies from 1 patient were confirmed to react with neurofascin 155 and 186. Serum from a ZIKV-infected patient without GBS displayed strong myelin-binding and putative antilipid antigen reaction characteristics. There was, however, no significant association of ZIKV-GBS with any known antiglycolipid antibodies. DISCUSSION Autoantibody responses in ZIKV-GBS target heterogeneous peripheral nerve antigens suggesting heterogeneity of the humoral immune response despite a common prodromal infection.
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Affiliation(s)
- Alexander J Davies
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cinta Lleixà
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ana M Siles
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Dawn S Gourlay
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Georgina Berridge
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanwisa Dejnirattisai
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Carolina Ramírez-Santana
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Juan-Manuel Anaya
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Andrew K Falconar
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Claudia M Romero-Vivas
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lyda Osorio
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Beatriz Parra
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gavin R Screaton
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Juthathip Mongkolsapaya
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Roman Fischer
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Carlos A Pardo
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Susan K Halstead
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Hugh J Willison
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Luis Querol
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Simon Rinaldi
- From the Nuffield Department of Clinical Neurosciences (A.J.D., S.R.), University of Oxford, John Radcliffe Hospital, UK; Neuromuscular Diseases Unit (C.L., A.M.S., L.Q.), Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para la Investigación Biomédica en red en Enfermedades Raras-(CIBERER) Madrid (C.L., A.M.S., L.Q.), Spain; Institute of Infection (D.S.G., S.K.H., H.J.W.), Immunity & Inflammation, University of Glasgow, University Place, UK; Target Discovery Institute (G.B., R.F.), NDM Research Building, University of Oxford, Old Road Campus, UK; Wellcome Centre for Human Genetics (W.D., G.R.S., J.M.), Nuffield Department of Medicine, University of Oxford, UK; Center for Autoimmune Diseases Research (CREA) (C.R.-S., J.-M.A.), Universidad del Rosario, Bogotá, Colombia; Departamento de Medicina (A.K.F., C.M.R.-V.), Universidad del Norte, Barranquilla, Colombia; Grupo de Epidemiología y Salud Poblacional (GESP) (L.O.,), School of Public Health, Universidad del Valle, Cali, Colombia; Department of Microbiology (B.P.), School of Basic Sciences, Universidad del Valle, Cali, Colombia; Dengue Hemorrhagic Fever Research Unit (J.M.), Office for Research and Development, Siriraj Hospital, Faculty of Medicine, Mahidol Univeristy, Bangkok, Thailand; Department of Neurology (C.A.P.), Johns Hopkins University School of Medicine, Baltimore, MD; and LifeFactors (J.-M.A.), Rionegro, Colombia; Division of Emerging Infectious Disease (W.D.), Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Burbelo PD, Castagnoli R, Shimizu C, Delmonte OM, Dobbs K, Discepolo V, Lo Vecchio A, Guarino A, Licciardi F, Ramenghi U, Rey-Jurado E, Vial C, Marseglia GL, Licari A, Montagna D, Rossi C, Montealegre Sanchez GA, Barron K, Warner BM, Chiorini JA, Espinosa Y, Noguera L, Dropulic L, Truong M, Gerstbacher D, Mató S, Kanegaye J, Tremoulet AH, Eisenstein EM, Su HC, Imberti L, Poli MC, Burns JC, Notarangelo LD, Cohen JI. Autoantibodies Against Proteins Previously Associated With Autoimmunity in Adult and Pediatric Patients With COVID-19 and Children With MIS-C. Front Immunol 2022; 13:841126. [PMID: 35360001 PMCID: PMC8962198 DOI: 10.3389/fimmu.2022.841126] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/16/2022] [Indexed: 01/08/2023] Open
Abstract
The antibody profile against autoantigens previously associated with autoimmune diseases and other human proteins in patients with COVID-19 or multisystem inflammatory syndrome in children (MIS-C) remains poorly defined. Here we show that 30% of adults with COVID-19 had autoantibodies against the lung antigen KCNRG, and 34% had antibodies to the SLE-associated Smith-D3 protein. Children with COVID-19 rarely had autoantibodies; one of 59 children had GAD65 autoantibodies associated with acute onset of insulin-dependent diabetes. While autoantibodies associated with SLE/Sjögren's syndrome (Ro52, Ro60, and La) and/or autoimmune gastritis (gastric ATPase) were detected in 74% (40/54) of MIS-C patients, further analysis of these patients and of children with Kawasaki disease (KD), showed that the administration of intravenous immunoglobulin (IVIG) was largely responsible for detection of these autoantibodies in both groups of patients. Monitoring in vivo decay of the autoantibodies in MIS-C children showed that the IVIG-derived Ro52, Ro60, and La autoantibodies declined to undetectable levels by 45-60 days, but gastric ATPase autoantibodies declined more slowly requiring >100 days until undetectable. Further testing of IgG and/or IgA antibodies against a subset of potential targets identified by published autoantigen array studies of MIS-C failed to detect autoantibodies against most (16/18) of these proteins in patients with MIS-C who had not received IVIG. However, Troponin C2 and KLHL12 autoantibodies were detected in 2 of 20 and 1 of 20 patients with MIS-C, respectively. Overall, these results suggest that IVIG therapy may be a confounding factor in autoantibody measurements in MIS-C and that antibodies against antigens associated with autoimmune diseases or other human proteins are uncommon in MIS-C.
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Affiliation(s)
- Peter D Burbelo
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, United States
| | - Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States.,Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Chisato Shimizu
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States
| | - Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Valentina Discepolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Alfredo Guarino
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Francesco Licciardi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatric Sciences, "Regina Margherita" Children's Hospital, University of Turin, Turin, Italy
| | - Ugo Ramenghi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatric Sciences, "Regina Margherita" Children's Hospital, University of Turin, Turin, Italy
| | - Emma Rey-Jurado
- Instituto de Ciencias e Innovación en Medicina (ICIM), Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Cecilia Vial
- Instituto de Ciencias e Innovación en Medicina (ICIM), Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Gian Luigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Daniela Montagna
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Camillo Rossi
- Direzione Sanitaria, ASST Spedali Civili, Brescia, Italy
| | - Gina A Montealegre Sanchez
- Intramural Clinical Management and Operations Branch (ICMOB), Division of Clinical Research NIAID, NIH, Bethesda, MD, United States
| | - Karyl Barron
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, NIH, Bethesda, MD, United States
| | - Blake M Warner
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, United States
| | - John A Chiorini
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, United States
| | | | - Loreani Noguera
- Instituto de Ciencias e Innovación en Medicina (ICIM), Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Lesia Dropulic
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Meng Truong
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Dana Gerstbacher
- Pediatric Rheumatology, Stanford Children's Hospital, Stanford, CA, United States
| | - Sayonara Mató
- Pediatric Infectious Diseases, Randall Children's Hospital at Legacy Emanuel, Portland, OR, United States
| | - John Kanegaye
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States
| | - Adriana H Tremoulet
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States
| | | | - Eli M Eisenstein
- Department of Pediatrics, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Helen C Su
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Luisa Imberti
- CREA Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Maria Cecilia Poli
- Instituto de Ciencias e Innovación en Medicina (ICIM), Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,Hospital Roberto del Río, Santiago, Chile
| | - Jane C Burns
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
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Gross CC, Schulte-Mecklenbeck A, Madireddy L, Pawlitzki M, Strippel C, Räuber S, Krämer J, Rolfes L, Ruck T, Beuker C, Schmidt-Pogoda A, Lohmann L, Schneider-Hohendorf T, Hahn T, Schwab N, Minnerup J, Melzer N, Klotz L, Meuth SG, Meyer zu Hörste G, Baranzini SE, Wiendl H. Classification of neurological diseases using multi-dimensional cerebrospinal fluid analysis. Brain 2021; 144:2625-2634. [PMID: 33848319 PMCID: PMC8557345 DOI: 10.1093/brain/awab147] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/19/2022] Open
Abstract
Although CSF analysis routinely enables the diagnosis of neurological diseases, it is mainly used for the gross distinction between infectious, autoimmune inflammatory, and degenerative disorders of the CNS. To investigate, whether a multi-dimensional cellular blood and CSF characterization can support the diagnosis of clinically similar neurological diseases, we analysed 546 patients with autoimmune neuroinflammatory, degenerative, or vascular conditions in a cross-sectional retrospective study. By combining feature selection with dimensionality reduction and machine learning approaches we identified pan-disease parameters that were altered across all autoimmune neuroinflammatory CNS diseases and differentiated them from other neurological conditions and inter-autoimmunity classifiers that subdifferentiate variants of CNS-directed autoimmunity. Pan-disease as well as diseases-specific changes formed a continuum, reflecting clinical disease evolution. A validation cohort of 231 independent patients confirmed that combining multiple parameters into composite scores can assist the classification of neurological patients. Overall, we showed that the integrated analysis of blood and CSF parameters improves the differential diagnosis of neurological diseases, thereby facilitating early treatment decisions.
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Affiliation(s)
- Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Correspondence to: Heinz Wiendl Department of Neurology with Institute of Translational Neurology University and University Hospital Münster; Albert-Schweitzer-Campus 1A1 48149 Münster, Germany E-mail: Correspondence may also be addressed to: Catharina C. Gross E-mail:
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Lohith Madireddy
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Saskia Räuber
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Lisa Lohmann
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tim Hahn
- Department of Psychiatry, University of Münster, 48149 Münster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Sergio E Baranzini
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Correspondence to: Heinz Wiendl Department of Neurology with Institute of Translational Neurology University and University Hospital Münster; Albert-Schweitzer-Campus 1A1 48149 Münster, Germany E-mail: Correspondence may also be addressed to: Catharina C. Gross E-mail:
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15
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Banks SA, Sechi E, Flanagan EP. Autoimmune encephalopathies presenting as dementia of subacute onset and rapid progression. Ther Adv Neurol Disord 2021; 14:1756286421998906. [PMID: 33796145 PMCID: PMC7983436 DOI: 10.1177/1756286421998906] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
The terms autoimmune dementia and autoimmune encephalopathy may be used interchangeably; autoimmune dementia is used here to emphasize its consideration in young-onset dementia, dementia with a subacute onset, and rapidly progressive dementia. Given their potential for reversibility, it is important to distinguish the rare autoimmune dementias from the much more common neurodegenerative dementias. The presence of certain clinical features [e.g. facio-brachial dystonic seizures that accompany anti-leucine-rich-glioma-inactivated-1 (LGI1) encephalitis that can mimic myoclonus] can be a major clue to the diagnosis. When possible, objective assessment of cognition with bedside testing or neuropsychological testing is useful to determine the degree of abnormality and serve as a baseline from which immunotherapy response can be judged. Magnetic resonance imaging (MRI) head and cerebrospinal fluid (CSF) analysis are useful to assess for inflammation that can support an autoimmune etiology. Assessing for neural autoantibody diagnostic biomarkers in serum and CSF in those with suggestive features can help confirm the diagnosis and guide cancer search in paraneoplastic autoimmune dementia. However, broad screening for neural antibodies in elderly patients with an insidious dementia is not recommended. Moreover, there are pitfalls to antibody testing that should be recognized and the high frequency of some antibodies in the general population limit their diagnostic utility [e.g., anti-thyroid peroxidase (TPO) antibodies]. Once the diagnosis is confirmed, both acute and maintenance immunotherapy can be utilized and treatment choice varies depending on the accompanying neural antibody present and the presence or absence of cancer. The target of the neural antibody biomarker may help predict treatment response and prognosis, with antibodies to cell-surface or synaptic antigens more responsive to immunotherapy and yielding a better overall prognosis than those with antibodies to intracellular targets. Neurologists should be aware that autoimmune dementias and encephalopathies are increasingly recognized in novel settings, including post herpes virus encephalitis and following immune-checkpoint inhibitor use.
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Affiliation(s)
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eoin P Flanagan
- Departments of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
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16
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Murphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T, Dean J, DeBiasi R, Desai J, Elrick MJ, Farias-Moeller R, Gombolay GY, Greenberg B, Harmelink M, Hong S, Hopkins SE, Oleszek J, Otten C, Sadowsky CL, Schreiner TL, Thakur KT, Van Haren K, Carballo CM, Chong PF, Fall A, Gowda VK, Helfferich J, Kira R, Lim M, Lopez EL, Wells EM, Yeh EA, Pardo CA. Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334-346. [PMID: 33357469 PMCID: PMC7909727 DOI: 10.1016/s0140-6736(20)32723-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
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Affiliation(s)
- Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica L Carpenter
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - Thomas Crawford
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Roberta DeBiasi
- Department of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Greenberg
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Harmelink
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sue Hong
- Division of Pediatric Critical Care, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Teri L Schreiner
- Department of Child Neurology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Carolina M Carballo
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Amary Fall
- Institut Pasteur de Dakar, Département de Virologie, Dakar, Senegal
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ming Lim
- Children's Neuroscience Center, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, and Faculty of Life Sciences, King's College, London, UK
| | - Eduardo L Lopez
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Elizabeth M Wells
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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17
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Gruber CN, Patel RS, Trachtman R, Lepow L, Amanat F, Krammer F, Wilson KM, Onel K, Geanon D, Tuballes K, Patel M, Mouskas K, O'Donnell T, Merritt E, Simons NW, Barcessat V, Del Valle DM, Udondem S, Kang G, Gangadharan S, Ofori-Amanfo G, Laserson U, Rahman A, Kim-Schulze S, Charney AW, Gnjatic S, Gelb BD, Merad M, Bogunovic D. Mapping Systemic Inflammation and Antibody Responses in Multisystem Inflammatory Syndrome in Children (MIS-C). Cell 2020; 183:982-995.e14. [PMID: 32991843 PMCID: PMC7489877 DOI: 10.1016/j.cell.2020.09.034] [Citation(s) in RCA: 404] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/28/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
Initially, children were thought to be spared from disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a month into the epidemic, a novel multisystem inflammatory syndrome in children (MIS-C) emerged. Herein, we report on the immune profiles of nine MIS-C cases. All MIS-C patients had evidence of prior SARS-CoV-2 exposure, mounting an antibody response with intact neutralization capability. Cytokine profiling identified elevated signatures of inflammation (IL-18 and IL-6), lymphocytic and myeloid chemotaxis and activation (CCL3, CCL4, and CDCP1), and mucosal immune dysregulation (IL-17A, CCL20, and CCL28). Immunophenotyping of peripheral blood revealed reductions of non-classical monocytes, and subsets of NK and T lymphocytes, suggesting extravasation to affected tissues. Finally, profiling the autoantigen reactivity of MIS-C plasma revealed both known disease-associated autoantibodies (anti-La) and novel candidates that recognize endothelial, gastrointestinal, and immune-cell antigens. All patients were treated with anti-IL-6R antibody and/or IVIG, which led to rapid disease resolution.
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Affiliation(s)
- Conor N Gruber
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Roosheel S Patel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Rebecca Trachtman
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Lauren Lepow
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Fatima Amanat
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Karen M Wilson
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Kenan Onel
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Daniel Geanon
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Kevin Tuballes
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Manishkumar Patel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Konstantinos Mouskas
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Timothy O'Donnell
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Elliot Merritt
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Nicole W Simons
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Vanessa Barcessat
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Diane M Del Valle
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Samantha Udondem
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Gurpawan Kang
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Sandeep Gangadharan
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - George Ofori-Amanfo
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Uri Laserson
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Adeeb Rahman
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Seunghee Kim-Schulze
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Alexander W Charney
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Sacha Gnjatic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Bruce D Gelb
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Miriam Merad
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Dusan Bogunovic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA; Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA.
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18
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Wang F, Tyberghein M. Reply to "Axonal" form of Guillain-Barré syndrome in a patient receiving oxaliplatin-based chemotherapy. Neurol Sci 2020; 42:1197-1198. [PMID: 32995990 DOI: 10.1007/s10072-020-04779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/26/2020] [Indexed: 10/23/2022]
Affiliation(s)
- François Wang
- Department of Clinical Neurophysiology, University of Liège, B35, 4000, Liège, Belgium.
| | - Maelle Tyberghein
- Department of Clinical Neurophysiology, University of Liège, B35, 4000, Liège, Belgium
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19
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Jia L, Zhang H. Axonal form of Guillain-Barré syndrome in a patient receiving oxaliplatin-based chemotherapy. Neurol Sci 2020; 42:365-366. [PMID: 32705491 DOI: 10.1007/s10072-020-04560-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Linpei Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongliang Zhang
- Department of Life Sciences, The National Natural Science Foundation of China, Shuangqing Road 83#, Beijing, 100085, China.
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20
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Gruber C, Patel R, Trachman R, Lepow L, Amanat F, Krammer F, Wilson KM, Onel K, Geanon D, Tuballes K, Patel M, Mouskas K, Simons N, Barcessat V, Valle DD, Udondem S, Kang G, Gangadharan S, Ofori-Amanfo G, Rahman A, Kim-Schulze S, Charney A, Gnjatic S, Gelb BD, Merad M, Bogunovic D. Mapping Systemic Inflammation and Antibody Responses in Multisystem Inflammatory Syndrome in Children (MIS-C). MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.07.04.20142752. [PMID: 32676612 PMCID: PMC7359537 DOI: 10.1101/2020.07.04.20142752] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Initially, the global outbreak of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spared children from severe disease. However, after the initial wave of infections, clusters of a novel hyperinflammatory disease have been reported in regions with ongoing SARS-CoV-2 epidemics. While the characteristic clinical features are becoming clear, the pathophysiology remains unknown. Herein, we report on the immune profiles of eight Multisystem Inflammatory Syndrome in Children (MIS-C) cases. We document that all MIS-C patients had evidence of prior SARS-CoV-2 exposure, mounting an antibody response with normal isotype-switching and neutralization capability. We further profiled the secreted immune response by high-dimensional cytokine assays, which identified elevated signatures of inflammation (IL-18 and IL-6), lymphocytic and myeloid chemotaxis and activation (CCL3, CCL4, and CDCP1) and mucosal immune dysregulation (IL-17A, CCL20, CCL28). Mass cytometry immunophenotyping of peripheral blood revealed reductions of mDC1 and non-classical monocytes, as well as both NK- and T- lymphocytes, suggesting extravasation to affected tissues. Markers of activated myeloid function were also evident, including upregulation of ICAM1 and FcγR1 in neutrophil and non-classical monocytes, well-documented markers in autoinflammation and autoimmunity that indicate enhanced antigen presentation and Fc-mediated responses. Finally, to assess the role for autoimmunity secondary to infection, we profiled the auto-antigen reactivity of MIS-C plasma, which revealed both known disease-associated autoantibodies (anti-La) and novel candidates that recognize endothelial, gastrointestinal and immune-cell antigens. All patients were treated with anti-IL6R antibody or IVIG, which led to rapid disease resolution tracking with normalization of inflammatory markers.
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Affiliation(s)
- Conor Gruber
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Roosheel Patel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Rebecca Trachman
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Lauren Lepow
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Fatima Amanat
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Karen M. Wilson
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Kenan Onel
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Daniel Geanon
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Kevin Tuballes
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Manishkumar Patel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Konstantinos Mouskas
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Nicole Simons
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Vanessa Barcessat
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Diane Del Valle
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Samantha Udondem
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Gurpawan Kang
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Sandeep Gangadharan
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - George Ofori-Amanfo
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Adeeb Rahman
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Seunghee Kim-Schulze
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Alexander Charney
- Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Sacha Gnjatic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Bruce D. Gelb
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Miriam Merad
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Dusan Bogunovic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, NY, NY, USA
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