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Ricciardi R, Latini E, Guida M, Koneczny I, Lucchi M, Maestri M, De Rosa A, Vincent A. Acetylcholinesterase inhibitors are ineffective in MuSK-antibody positive myasthenia gravis: Results of a study on 202 patients. J Neurol Sci 2024; 461:123047. [PMID: 38759248 DOI: 10.1016/j.jns.2024.123047] [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: 02/06/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) with MuSK antibodies (MuSK-MG) represents a distinct subtype with different responses to treatments compared to patients with AChR antibodies, especially in terms of tolerance to acetylcholinesterase inhibitors (AChEI). However, AChEI are often used as first line symptomatic treatment in MuSK-MG, despite reports that they are poorly tolerated, seldom effective or even deleterious. METHODS We analyzed demographic, clinical and therapeutic responses and side-effects in the large cohort of 202 MuSK-MG patients cared for at the MG Clinic of Azienda Ospedaliero-Universitaria Pisana. RESULTS 165 patients had received AChEI at first evaluation. Only 7/165 patients (4.2%) reported an initial clinical benefit. Conversely, 76.9% of patients reported at least one side effect, most commonly neuromuscular hyperexcitability (68.4%), gastrointestinal (53.9%) and neurovegetative (35.8%) disturbances. 56 (33.9%) patients reported a concomitant worsening of muscle weakness and twelve patients (7.3%) suffered a cholinergic crisis. According to these patients, the severity of cholinergic side effects was greater at higher doses of AChEI, but side effects occurred regardless of the dose administered and ceased once the drug was discontinued. CONCLUSIONS This is the largest population of MuSK-MG patients reported for perceived responsiveness and tolerance to AChEI treatment. Our obervations strongly suggest avoiding this treatment in MuSK-MG.
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Affiliation(s)
- R Ricciardi
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy; CardioThoracic and Vascular Surgery Department, University of Pisa, Italy
| | - E Latini
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy.
| | - M Guida
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - I Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria
| | - M Lucchi
- CardioThoracic and Vascular Surgery Department, University of Pisa, Italy
| | - M Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - A De Rosa
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - A Vincent
- Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
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Gaig C, Sabater L. New knowledge on anti-IgLON5 disease. Curr Opin Neurol 2024; 37:316-321. [PMID: 38563128 PMCID: PMC11064895 DOI: 10.1097/wco.0000000000001271] [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] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Anti-IgLON5 disease is characterized by a distinctive sleep disorder, associated with a heterogeneous spectrum of neurological symptoms. Initial autopsies showed a novel neuronal tauopathy predominantly located in the tegmentum of the brainstem. Recently, new diagnostic red flags, biomarkers predictors of response to immunotherapy, and novel insights into the autoimmune pathogenesis of the disease have been reported. RECENT FINDINGS Patients with diagnosis of neurodegenerative dementia, progressive supranuclear palsy (PSP) or with motor-neuron disease (MND)-like syndrome have been reported to have IgLON5 antibodies, which are the hallmark of anti-IgLON5 disease. Second, low levels of neurofilament light chain in serum and cerebrospinal fluid of patients at disease onset could be a predictor of immunotherapy response. Recent neuropathological studies indicate that the neuronal tau deposits occur late in the course of the disease. Moreover, IgLON5 antibodies induce cytoskeletal changes in cultured hippocampal neurons suggesting that the tauopathy could be secondary of the IgLON5 antibody effects. SUMMARY Anti-IgLON5 disease can mimic and should be considered in atypical presentations of MND, neurodegenerative dementia and PSP. Neurofilament light chain levels seem promising biomarker for disease prognosis. Finally, the neuropathological and in vitro experimental studies strengthen the autoimmune hypothesis of the disease.
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Affiliation(s)
- Carles Gaig
- Service of Neurology, Hospital Clinic de Barcelona
| | - Lidia Sabater
- Neuroimmunology Program, Fundació de Recerca Clínic Barcelona-Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
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3
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Ünlü S, Sánchez Navarro BG, Cakan E, Berchtold D, Meleka Hanna R, Vural S, Vural A, Meisel A, Fichtner ML. Exploring the depths of IgG4: insights into autoimmunity and novel treatments. Front Immunol 2024; 15:1346671. [PMID: 38698867 PMCID: PMC11063302 DOI: 10.3389/fimmu.2024.1346671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 05/05/2024] Open
Abstract
IgG4 subclass antibodies represent the rarest subclass of IgG antibodies, comprising only 3-5% of antibodies circulating in the bloodstream. These antibodies possess unique structural features, notably their ability to undergo a process known as fragment-antigen binding (Fab)-arm exchange, wherein they exchange half-molecules with other IgG4 antibodies. Functionally, IgG4 antibodies primarily block and exert immunomodulatory effects, particularly in the context of IgE isotype-mediated hypersensitivity reactions. In the context of disease, IgG4 antibodies are prominently observed in various autoimmune diseases combined under the term IgG4 autoimmune diseases (IgG4-AID). These diseases include myasthenia gravis (MG) with autoantibodies against muscle-specific tyrosine kinase (MuSK), nodo-paranodopathies with autoantibodies against paranodal and nodal proteins, pemphigus vulgaris and foliaceus with antibodies against desmoglein and encephalitis with antibodies against LGI1/CASPR2. Additionally, IgG4 antibodies are a prominent feature in the rare entity of IgG4 related disease (IgG4-RD). Intriguingly, both IgG4-AID and IgG4-RD demonstrate a remarkable responsiveness to anti-CD20-mediated B cell depletion therapy (BCDT), suggesting shared underlying immunopathologies. This review aims to provide a comprehensive exploration of B cells, antibody subclasses, and their general properties before examining the distinctive characteristics of IgG4 subclass antibodies in the context of health, IgG4-AID and IgG4-RD. Furthermore, we will examine potential therapeutic strategies for these conditions, with a special focus on leveraging insights gained from anti-CD20-mediated BCDT. Through this analysis, we aim to enhance our understanding of the pathogenesis of IgG4-mediated diseases and identify promising possibilities for targeted therapeutic intervention.
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Affiliation(s)
- Selen Ünlü
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Koç University School of Medicine, Istanbul, Türkiye
| | - Blanca G. Sánchez Navarro
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Elif Cakan
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
| | - Daniel Berchtold
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rafael Meleka Hanna
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Secil Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Dermatology and Venereology, Koç University School of Medicine, İstanbul, Türkiye
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology, Koç University School of Medicine, İstanbul, Türkiye
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam L. Fichtner
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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4
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Kmezic I, Press R, Glenewinkel H, Doppler K, Appeltshauser L. Low-dose rituximab treatment in a patient with anti-neurofascin-155 IgG4 autoimmune nodopathy. J Neuroimmunol 2024; 389:578326. [PMID: 38422690 DOI: 10.1016/j.jneuroim.2024.578326] [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: 12/28/2023] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 03/02/2024]
Abstract
Autoimmune nodopathy is a new entity of immune-mediated neuropathies associated with antibodies against nodal-paranodal epitopes. We present a detailed clinical and serological work-up of a patient with autoimmune nodopathy with anti-neurofascin-155 (anti-NF-155) IgG4 antibodies who was treated with low-dose (500 mg) rituximab, which led to a decrease of anti-NF-155 antibody titer, depletion of B cells, normalization of the levels of neurofilament light chain in serum, and significant clinical improvement. This case suggests that a low-dose rituximab could be as effective as previously reported much higher doses, and presumably with a lower risk of adverse effects and infections.
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Affiliation(s)
- Ivan Kmezic
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Rayomand Press
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Helena Glenewinkel
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Kathrin Doppler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
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5
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Dziadkowiak E, Baczyńska D, Waliszewska-Prosół M. MuSK Myasthenia Gravis-Potential Pathomechanisms and Treatment Directed against Specific Targets. Cells 2024; 13:556. [PMID: 38534400 DOI: 10.3390/cells13060556] [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: 02/13/2024] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which autoantibodies target structures within the neuromuscular junction, affecting neuromuscular transmission. Muscle-specific tyrosine kinase receptor-associated MG (MuSK-MG) is a rare, often more severe, subtype of the disease with different pathogenesis and specific clinical features. It is characterized by a more severe clinical course, more frequent complications, and often inadequate response to treatment. Here, we review the current state of knowledge about potential pathomechanisms of the MuSK-MG and their therapeutic implications as well as ongoing research in this field, with reference to key points of immune-mediated processes involved in the background of myasthenia gravis.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Dagmara Baczyńska
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-556 Wroclaw, Poland
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Rashed HR, Niu Z, Dyck PJ, Dyck PJB, Mauermann ML, Berini SE, Dubey D, Mills JR, Staff NP, Wu Y, Spinner RE, Dasari S, Klein CJ. Nerve transcriptomes in autoimmune and genetic demyelinating neuropathies: Pathogenic pathway assessment of nerve demyelination. J Neuroimmunol 2023; 384:578220. [PMID: 37857228 DOI: 10.1016/j.jneuroim.2023.578220] [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: 07/03/2023] [Revised: 09/03/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Abstract
The pathogenesis of autoimmune demyelinating neuropathies is poorly understood compared to inherited demyelinating forms. We performed whole transcriptome (RNA-Seq) using nerve biopsy tissues of patients with different autoimmune and inherited demyelinating neuropathies (CIDP n = 10, POEMS n = 18, DADS n = 3, CMT1 n = 3) versus healthy controls (n = 6). A limited number of differentially expressed genes compared to healthy controls were identified (POEMS = 125, DADS = 15, CMT = 14, CIDP = 5). Divergent pathogenic pathways including inflammatory, demyelinating and neurite regeneration such as with the triggering receptor expressed on myeloid cells (TREM1) part of the immunoglobulin superfamily and RhoGD1 are found. Shared and discordant pathogenic injury are discovered between autoimmune and inherited forms.
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Affiliation(s)
- Hebatallah R Rashed
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Zhiyv Niu
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Peter J Dyck
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - P James B Dyck
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Michelle L Mauermann
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Nathan P Staff
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Yanhong Wu
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Robert E Spinner
- Department of Neurosurgery, Rochester, MN, United States of America
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America.
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7
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Akan O, Baysal L, Uzunhan TA, Tüzün E. Generalized Peripheric Nerve Hyperexcitability with Neuropathy: Case Series with Long-Term Outcome. Noro Psikiyatr Ars 2023; 61:184-188. [PMID: 38868855 PMCID: PMC11165604 DOI: 10.29399/npa.28430] [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: 02/08/2023] [Accepted: 04/29/2023] [Indexed: 06/14/2024] Open
Abstract
Introduction Peripheric nerve hyperexcitability (PNH) syndromes are a rare, heterogenous group of diseases characterized by continuous muscle overactivity due to spontaneous discharges of the lower motor neurons. Case Series Here we report four patients presented with painful cramps, generalized muscle twitches and lower extremity weakness. All patients had evidence of neuropathy and neuromyotonic discharges on electrodiagnostic studies. Screening for a broad panel of anti-neuronal antibodies proved uncharacterized neuropil antibodies in one patient. Despite extensive serologic and genetic investigations, no definitive etiology was found in our cohort. One out of three patients responded well to immunotherapy. No other diseases including malignancy appeared for 1.5-3 years follow-up duration. Conclusion Our case series indicate a putatively high prevalence of neuropathy in PNH and emphasize anti-neuronal antibody positivity and early diagnosis as potential favorable prognostic factors.
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Affiliation(s)
- Onur Akan
- University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Department of Neurology, Istanbul, Turkey
| | - Leyla Baysal
- University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Department of Neurology, Istanbul, Turkey
| | - Tuğçe Aksu Uzunhan
- University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Department of Child Neurology, Istanbul, Turkey
| | - Erdem Tüzün
- Istanbul University, Aziz Sancar Institute of Experimental Medicine, Department of Neuroscience, Istanbul, Turkey
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8
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Tadros AR, Atteh G, Vargas DL, Cole EF, Feldman RJ. Autoimmune encephalitis associated with autoimmune blistering diseases: A case series and retrospective review. JAAD Case Rep 2023; 37:92-97. [PMID: 37360651 PMCID: PMC10285499 DOI: 10.1016/j.jdcr.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
- Andrew R. Tadros
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - George Atteh
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Diana L. Vargas
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Emily F. Cole
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Ron J. Feldman
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
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9
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Dalmau J, Dalakas MC, Kolson DL, Paul F, Sánchez-Valle R, Zamvil SS. N2 Year in Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/1/e200076. [PMID: 36596717 PMCID: PMC9827124 DOI: 10.1212/nxi.0000000000200076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Josep Dalmau
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco.
| | - Marinos C Dalakas
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Dennis L Kolson
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Friedemann Paul
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Raquel Sánchez-Valle
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
| | - Scott S Zamvil
- From the Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (J.D., R.S.-V.), Hospital Clínic, Universitat de Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Department of Neurology (J.D., D.L.K.), University of Pennsylvania, Philadelphia; Neuroimmunology Unit (M.C.D.), National and Kapodistrian University of Athens Medical School, Greece; Thomas Jefferson University (M.C.D.), Philadelphia, PA; Charité-Universitätsmedizin Berlin und Max Delbrueck Center for Molecular Medicine (F.P.), Germany; and Department of Neurology (S.S.Z.), Weill Institute for Neurosciences and Program in Immunology, University of California, San Francisco
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10
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Kutzscher AE, Silkiss RZ. IgG4-related disease presenting with profound bilateral orbital and adnexal inflammation. Am J Ophthalmol Case Rep 2022; 29:101782. [PMID: 36605182 PMCID: PMC9807738 DOI: 10.1016/j.ajoc.2022.101782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/24/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose IgG4-related disease is an immune-mediated fibroinflammatory condition that can affect almost every major organ system. Orbital and adnexal involvement in IgG4-related disease though not uncommon can be varied depending on the site of the lymphoplasmacytic infiltration. This case of profound bilateral orbital inflammation is presented to demonstrate the significant clinical manifestations of IgG4-related ophthalmic disease. Observations A 52-year-old man with a remote and seemingly unrelated history of lymphadenopathy presented to the Oculoplastics clinic with massive bilateral upper and lower lid swelling and induration. Hematologic testing demonstrated an elevation in serum IgG4 - a non-specific finding seen in various infectious, inflammatory, and malignant processes. Imaging demonstrated diffuse enlargement of orbital structures, including the lacrimal glands and extraocular muscles, as well as inflammatory changes of the adnexal and retrobulbar soft tissue. Orbital biopsy was required to confirm the diagnosis of IgG4-related ophthalmic disease. Conclusions and Importance IgG4-related ophthalmic disease presents with various non-specific clinical signs and symptoms. The most common presentations include dacryoadenitis, enlarged orbital nerves, and orbital fat involvement; however, the extent of involvement both locally and systemically varies greatly. Clinical findings and imaging are helpful in narrowing the differential diagnosis; however, biopsy for histopathologic examination is essential to confirm IgG4-related disease. Physicians must maintain a high level of suspicion for the disease for proper management.
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Affiliation(s)
- Anne E. Kutzscher
- California Pacific Medical Center, 711 Van Ness Ave #250, San Francisco, CA, 94102, USA,Corresponding author. 711 Van Ness Ave #250, San Francisco, CA, 94102, USA.
| | - Rona Z. Silkiss
- California Pacific Medical Center, 711 Van Ness Ave #250, San Francisco, CA, 94102, USA,Silkiss Eye Surgery, 711 Van Ness Ave #340, San Francisco, CA, 94102, USA
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11
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Bjerknes TL, Steihaug OM, Haugen M, Hjelland IE, Vedeler CA. Case report: Pain in anti-DPPX encephalitis. Front Neurol 2022; 13:1091688. [PMID: 36588910 PMCID: PMC9794743 DOI: 10.3389/fneur.2022.1091688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Encephalitis due to antibodies targeting dipeptidyl-peptidase-like protein 6 (DPPX), a potassium channel subunit, is rare. The illness is typically characterized by a triad of weight loss, CNS hyperexcitability and cognitive symptoms, but recent reports suggest that the clinical picture may be more heterogeneous. Here, we describe the case of a 63-year-old female who was admitted to the hospital with severe extremity pain, which had been preceded by diarrhea and weight loss. She later developed cognitive changes, and her general condition rapidly deteriorated. Extensive workup did not reveal gastrointestinal illness or underlying malignancies. MRI of the brain was normal. Analyses of blood and cerebrospinal fluid showed normal cell counts but high titres of DPPX antibodies in blood and cerebrospinal fluid. The patient was treated with intravenous methylprednisolone followed by rituximab. At 1-year follow-up, she was without pain and had completely recovered. In this case, DPPX-associated autoimmune encephalitis was dominated by severe extremity pain, illustrating that sensory symptoms may be one of the main complaints in these patients. It is important for clinicians to be aware of the heterogeneous clinical picture in this serious condition, since correct diagnosis and treatment with immunosuppressants are associated with favorable prognosis.
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Affiliation(s)
- Tale L. Bjerknes
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,*Correspondence: Tale L. Bjerknes
| | | | - Mette Haugen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ina Elen Hjelland
- Department of Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | - Christian Alexander Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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12
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BOCH K, LANGAN EA, VAN BEEK N, KRIDIN K, SCHMIDT E, ZILLIKENS D, LUDWIG RJ, HAMMERS CM, BIEBER K. Faster IgG4 Depletion Kinetics Observed for Anti-Desmoglein 3 Autoantibodies Following Rituximab Treatment in Patients with Pemphigus Vulgaris. Acta Derm Venereol 2022; 102:adv00835. [PMID: 36511332 PMCID: PMC9811284 DOI: 10.2340/actadv.v102.4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Katharina BOCH
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany
| | - Ewan A. LANGAN
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany,Manchester Sciences, University of Manchester, Manchester, UK
| | - Nina VAN BEEK
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Khalaf KRIDIN
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Enno SCHMIDT
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef ZILLIKENS
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany
| | - Ralf J. LUDWIG
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph M. HAMMERS
- Department of Dermatology, University of Luebeck, Ratzeburger Allee 160, DE-23562 Luebeck, Germany,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany,Department of Dermatology, Christian-Albrechts-University, Kiel, Germany
| | - Katja BIEBER
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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13
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McCombe PA, Hardy TA, Nona RJ, Greer JM. Sex differences in Guillain Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and experimental autoimmune neuritis. Front Immunol 2022; 13:1038411. [PMID: 36569912 PMCID: PMC9780466 DOI: 10.3389/fimmu.2022.1038411] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Guillain Barré syndrome (GBS) and its variants, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP and its variants, are regarded as immune mediated neuropathies. Unlike in many autoimmune disorders, GBS and CIDP are more common in males than females. Sex is not a clear predictor of outcome. Experimental autoimmune neuritis (EAN) is an animal model of these diseases, but there are no studies of the effects of sex in EAN. The pathogenesis of GBS and CIDP involves immune response to non-protein antigens, antigen presentation through non-conventional T cells and, in CIDP with nodopathy, IgG4 antibody responses to antigens. There are some reported sex differences in some of these elements of the immune system and we speculate that these sex differences could contribute to the male predominance of these diseases, and suggest that sex differences in peripheral nerves is a topic worthy of further study.
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Affiliation(s)
- Pamela A. McCombe
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia,*Correspondence: Pamela A. McCombe,
| | - Todd A. Hardy
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia,Brain & Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert J. Nona
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Judith M. Greer
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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14
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Dalakas MC, Latov N, Kuitwaard K. Intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): mechanisms of action and clinical and genetic considerations. Expert Rev Neurother 2022; 22:953-962. [PMID: 36645654 DOI: 10.1080/14737175.2022.2169134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune peripheral nerve disorder that is characterized by subacute onset, progressive or relapsing weakness, and sensory deficits. Proven treatments include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. This review focuses on the mechanisms of action, pharmacodynamics, genetic variations, and disease characteristics that can affect the efficacy of IVIg. AREAS COVERED The proposed mechanisms of action of IVIg that can mediate its therapeutic effects are reviewed. These include anti-idiotypic interactions, inhibition of neonatal Fc receptors (FcRn), anti-complement activity, upregulation of inhibitory FcγRIIB receptors, and downregulation of macrophage activation or co-stimulatory and adhesion molecules. Clinical and genetic factors that can affect the therapeutic response include misdiagnosis, degree of axonal damage, pharmacokinetic variability, and genetic variations. EXPERT OPINION The mechanisms of action of IVIg in CIDP and their relative contribution to its efficacy are subject of ongoing investigation. Studies in other autoimmune neurological conditions, in addition, highlight the role of key immunopathological pathways and factors that are likely to be affected. Further investigation into the pathogenesis of CIDP and the mechanisms of action of IVIg may lead to the development of improved diagnostics, better utilization of IVIg, and more targeted and effective therapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson Neuroimmunology Unit, Philadelphia, PA and National and Department of Pathophysiology, Kapodistrian University of Athens, Greece
| | - Norman Latov
- Neuroimmunology Unit, Weill Cornell Medical College, New York, NY, USA
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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15
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Zhang YZ, Ni Y, Gao YN, Shen DD, He L, Yin D, Meng HY, Zhou QM, Hu J, Chen S. Anti-IgLON5 disease: a novel topic beyond neuroimmunology. Neural Regen Res 2022; 18:1017-1022. [PMID: 36254983 PMCID: PMC9827781 DOI: 10.4103/1673-5374.355742] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Anti-IgLON5 disease is a recently defined autoimmune disorder of the nervous system associated with autoantibodies against IgLON5. Given its broad clinical spectrum and extremely complex pathogenesis, as well as difficulties in its early diagnosis and treatment, anti-IgLON5 disease has become the subject of considerable research attention in the field of neuroimmunology. Anti-IgLON5 disease has characteristics of both autoimmunity and neurodegeneration due to the unique activity of the anti-IgLON5 antibody. Neuropathologic examination revealed the presence of a tauopathy preferentially affecting the hypothalamus and brainstem tegmentum, potentially broadening our understanding of tauopathies. In contrast to that seen with other autoimmune encephalitis-related antibodies, basic studies have demonstrated that IgLON5 antibody-induced neuronal damage and degeneration are irreversible, indicative of a potential link between autoimmunity and neurodegeneration in anti-IgLON5 disease. Herein, we comprehensively review and discuss basic and clinical studies relating to anti-IgLON5 disease to better understand this complicated disorder.
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Affiliation(s)
- Yi-ZongHeng Zhang
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - You Ni
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Ning Gao
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ding-Ding Shen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Lu He
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dou Yin
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huan-Yu Meng
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin-Ming Zhou
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
| | - Ji Hu
- Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China,School of Life Science and Technology, ShanghaiTech University, Shanghai, China,Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
| | - Sheng Chen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
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16
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Dalakas MC, Wiendl H. Therapeutic Antibodies in Neurological Diseases: Witnessing the Continuation of the Impressive Success in Neuro-Immunotherapies. Neurotherapeutics 2022; 19:687-690. [PMID: 35831746 PMCID: PMC9281281 DOI: 10.1007/s13311-022-01266-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marinos C Dalakas
- Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
- Brain and Mind Center, University of Sydney, Sydney, Australia
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