Treatment Options in Refractory Autoimmune Encephalitis

Post-vaccinal seronegative autoimmune encephalitis following recombinant zoster vaccination in two immunocompetent patients

BACKGROUND

Varicella Zoster Virus (VZV) causes varicella as a primary infection and establishes latency in sensory ganglia. Reactivation in adults leads to herpes zoster (HZ). A highly effective recombinant zoster vaccine (Shingrix®) was recently developed to prevent HZ. While vaccine safety data is reassuring, we report two cases of post-vaccinal seronegative autoimmune encephalitis (AE) following the first dose of the Shingrix® vaccine. CASE 1: A 67-year-old male surgeon presented one week after receiving the vaccine with a one-day history of dizziness, fatigue, and insomnia, followed the next day by confusion, agitation, terrifying visual hallucinations, paraphasic errors, and echolalia. Brain imaging and cerebrospinal fluid (CSF) analysis were unremarkable. The CSF multiplex polymerase chain reaction (PCR) panel targeting 14 bacterial and viral pathogens associated with meningitis/encephalitis was negative. All known AE antibodies were also negative. The patient initially improved with empiric anti-meningitis/encephalitis therapy, including a two-day course of steroids but he relapsed shortly after stopping the steroids, necessitating re-admission. Pulse steroid therapy followed by plasmapheresis led to full recovery. CASE 2: A 50-year-old female pediatrician presented with acute confusion nine days after the Shingrix® vaccination. CSF analysis showed lymphocytic-predominant mild pleocytosis and elevated protein, but brain imaging was unremarkable. The CSF meningitis/encephalitis PCR panel and AE antibodies were negative. Pulse steroid therapy and plasmapheresis led to full recovery.

CONCLUSIONS

These two cases highlight the potential for AE following the administration of the Shingrix® vaccine and underscore the importance of prompt recognition and aggressive immunotherapy to prevent morbidity and mortality.

Intrathecal treatment of Anti-N-Methyl-D-Aspartate receptor encephalitis: a promising approach for refractory cases

BACKGROUND

Anti-N-methyl-D-aspartate receptor encephalitis is a severe neurological disorder. While standard treatments work for many patients, up to 25% are resistant to these treatments. In such challenging cases, there is growing interest in using intrathecal approaches.

METHODS

A narrative review of relevant papers was conducted.

RESULTS

Case reports and case series have demonstrated the successful use of intrathecal methotrexate, either alone or in combination with steroids, particularly in pediatric patients. Additionally, intrathecal rituximab has shown promise in select cases.

CONCLUSIONS

Although outcomes vary, this approach appears to be safe and has the potential to rescue refractory cases.

Hashimoto's Encephalopathy: Clinical Features, Therapeutic Strategies, and Rehabilitation Approaches

Hashimoto's encephalopathy (HE), also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), is an autoimmune disorder with heterogeneous presentation that poses diagnostic challenges. This review synthesizes the current literature to clarify the clinical, laboratory, and radiological features of SREAT/HE, including the diagnostic utility of thyroid peroxidase (TPO) antibodies, cerebrospinal fluid (CSF) abnormalities, and neuroimaging findings. Cognitive impairment and behavioral changes are common in HE, but specific manifestations vary widely, which can lead to misdiagnosis. While elevated TPO antibodies are frequently observed, a direct causal relationship with HE is unlikely, and their presence may indicate a general state of autoimmunity. Corticosteroids remain the cornerstone of treatment, although responses vary, and alternative immunosuppressive agents or intravenous immunoglobulin may be needed in some cases. Evidence regarding rehabilitation for people affected by HE is limited, but neurorehabilitation strategies adapted from other neurological conditions, including cognitive re-education (CR), physical therapy, and psychosocial support, may be beneficial. Further research is needed to elucidate the underlying mechanisms of SREAT, refine the diagnostic criteria, and develop more targeted and effective therapies, including rehabilitation strategies, for this debilitating neurological disorder.

Individualized therapy guided by single-cell sequencing in anti-GABAAR encephalitis

We presented a patient with refractory anti-GABAA-R encephalitis, and constructed libraries for single-cell sequencing from the patient's peripheral blood mononuclear cells (PBMCs), cerebrospinal fluid cells, as well as four healthy volunteer's PBMCs. A distinct group of monoclonal CD8+ T cells and an abnormal JAK-STAT signaling pathway was implicated in the disease. The cross-reactive protein LIM-domain-only protein 5 (LMO5) identified in the patient's thymoma, prompted the activation of the specific CD8+ T cells. Furthermore, in vitro analysis revealed the involvement of the JAK-STAT pathway in LMO5-induced CD8+T cell activation, a process effectively suppressed by tofacitinib, which improved the patient's clinical outcome.

Causal relationships between immune cell phenotypes and primary glomerular diseases: genetic evidence from bidirectional Mendelian randomization study

Background

Primary glomerular diseases (PGDs), including nephrotic syndrome (NS), membranous nephropathy (MN), and IgA nephropathy (IgAN), are complex renal conditions influenced by immune system dysregulation. Although associations between immune cell phenotypes and PGDs have been observed, the precise causal relationships have not been fully elucidated.

Methods

Utilizing genetic association data from genome-wide association studies (GWASs), we investigated 731 immunophenotypes in relation to PGDs. A bidirectional two-sample Mendelian randomization (MR) approach, primarily employing inverse variance weighting (IVW), was conducted to establish causality. MR-Egger, weighted median, simple mode, and weighted mode were used as complementary methods to reinforce the robustness and validity of the results. Sensitivity analyses further validated the sensitivity and stability of our results.

Results

We identified 38 immunophenotypes suggestively related to IgAN, with 20 as risk factors and 18 as protective effects. Six immunophenotypes remained significant after Bonferroni correction: The percentage of CD25hi among T cells; the percentage of CD25hi CD45RA- CD4 not T regulatory (Treg) among T cells; the percentage of CD25hi CD45RA- CD4 not Treg within the CD4+ T cell population; CX3CR1 expression on monocytes; CD40 expression on monocytes; and CD64 expression on CD14+ CD16- monocytes. In the validation analysis of IgAN, CD3 expression on effector memory CD4+ T cells further confirmed the predisposing risk role of effector memory T cells in the development of IgAN. Additionally, the MR analysis demonstrated suggestive associations between 25 immunophenotypes and MN (8 risk factors and 17 protective factors), as well as between 22 immunophenotypes and NS (10 risk factors and 12 protective factors). Last, by intersecting the immunophenotypes showing suggestive associations with PGDs, we identified two common immunophenotypes shared by IgAN and MN, three by IgAN and NS, and one by MN and NS.

Conclusions

This genetic-level investigation uncovers causal associations between immunophenotypes and PGDs, providing valuable insights into the immunological underpinnings of PGDs. Our findings suggest potential targets for treatment strategies, thereby facilitating more personalized and effective therapeutic approaches in PGDs management.

Interleukin-2 and its receptors: Implications and therapeutic prospects in immune-mediated disorders of central nervous system

Interleukin-2 (IL-2), the first cloned cytokine, is a multifunctional molecule with diverse cellular origins. As a pivotal T-cell growth factor, IL-2 is crucial for T-cell proliferation and the generation of effector and memory cells. Besides, IL-2 and its receptor (IL-2R) are expressed in various cell types within the brain and have been implicated in the pathogenesis of several neurological disorders. In conditions characterized by primary or secondary inflammatory processes, such as multiple sclerosis, Alzheimer's disease, ischemic stroke, and encephalitis, IL-2/IL-2R expression exhibits region- and subtype-specific and variations associated with disease stages in plasma, cerebrospinal fluid (CSF), and brain tissues. These variations highlight the potential of IL-2/IL-2R as promising diagnostic and prognostic biomarkers, as well as therapeutic targets. This review provides a comprehensive summary of the roles, expression patterns, and regulatory mechanisms of IL-2/IL-2R in immune-mediated disorders of the central nervous system (CNS), with particular emphasis on the impact of genetic polymorphisms in IL-2 and IL-2R subunits on disease susceptibility and progression. In addition, the research advances in IL-2/IL-2R-targeted therapies are also discussed, offering novel insights into the immunotherapeutic strategies for CNS diseases.

Autoimmune dementia

PURPOSE OF REVIEW

The aim of this review is to summarize clinical, radiological and laboratory findings in autoimmune dementia, to help clinicians in promptly identify this elusive condition.

RECENT FINDINGS

The rapid advances in the field of autoimmune neurology have led to the discovery of novel antibodies and associated disorders, which are more frequent than previously hypothesized. The correct and prompt identification of cognitive decline of autoimmune origin is vital to ensure early treatment and better outcomes. The diagnosis of autoimmune dementia relies on specific clinical and radiological features and on the detection of specific autoantibodies. Autoantibody specificities predict response to treatment and the occurrence of cancer. In recent years, the differential diagnosis of autoimmune dementia has become more relevant, as the overinterpretation of antibody results, clinical and radiological findings may lead to an erroneous diagnosis of autoimmune dementia, with potential harm to patients due to inappropriate exposure to immunosuppressants.

SUMMARY

Autoimmune dementia is a potentially treatable condition and should not be missed in clinical practice given the potential for reversibility with immunotherapy. The diagnosis of autoimmune dementia relies on a comprehensive review of clinical, radiological and laboratory data, and exclusion of other causes of dementia.

Toward curing neurological autoimmune disorders: Biomarkers, immunological mechanisms, and therapeutic targets

Autoimmune neurology is a rapidly expanding field driven by the discovery of neuroglial autoantibodies and encompassing a myriad of conditions affecting every level of the nervous system. Traditionally, autoantibodies targeting intracellular antigens are considered markers of T cell-mediated cytotoxicity, while those targeting extracellular antigens are viewed as pathogenic drivers of disease. However, recent advances highlight complex interactions between these immune mechanisms, suggesting a continuum of immunopathogenesis. The breakdown of immune tolerance, central to these conditions, is affected by modifiable and non-modifiable risk factors such as genetic predisposition, infections, and malignancy. While significant therapeutic advancements have revolutionized treatment of certain diseases, such as neuromyelitis optica, our understanding of many others, particularly T cell-mediated conditions, remains limited, with fewer treatment options available. Future research should focus on improving effector function modeling and deepening our understanding of the factors influencing immune tolerance, with the goal of providing novel treatment options and improving patient care.

Tofacitinib prevents depressive-like behaviors through decreased hippocampal microgliosis and increased BDNF levels in both LPS-induced and CSDS-induced mice

Depressive disorders are a global mental health challenge that is closely linked to inflammation, especially in the post-COVID-19 era. The JAK-STAT pathway, which is primarily associated with inflammatory responses, is not fully characterized in the context of depressive disorders. Recently, a phase 3 retrospective cohort analysis heightened that the marketed JAK inhibitor tofacitinib is beyond immune diseases and has potential for preventing mood disorders. Inspired by these clinical facts, we investigated the role of the JAK-STAT signaling pathway in depression and comprehensively assessed the antidepressant effect of tofacitinib. We found that aberrant activation of the JAK-STAT pathway is highly conserved in the hippocampus of classical depressive mouse models: LPS-induced and chronic social defeat stress (CSDS)-induced depressive mice. Mechanistically, the JAK-STAT pathway mediates proinflammatory cytokine production and microgliosis, leading to synaptic defects in the hippocampus of both depressive models. Remarkably, the JAK inhibitor tofacitinib effectively reverses these phenomena, contributing to its antidepressant effect. These findings indicate that the JAK/STAT pathway could be implicated in depressive disorders, and suggest that the JAK inhibitor tofacitinib has a potential translational implication for preventing mood disorders far beyond its current indications.

Clinical characteristics, immunological alteration and distinction of MOG-IgG-associated disorders and GFAP-IgG-associated disorders

The classification of autoimmune encephalitis (AE) is based on the presence of different types of antibodies. Currently, the clinical manifestations and treatment regimens of patients with all types of AE exhibit similarities. However, the presence of immunological distinctions among different types of AE remains uncertain. In this study, we prospectively collected clinical data, as well as blood and cerebrospinal fluid (CSF) samples from patients diagnosed with MOG antibody-associated disease (MOGAD) or GFAP astrocytopathy (GFAP-A), in order to assess changes in inflammatory biomarkers such as immunoglobulin oligoclonal bands, cytokines in serum and CSF, as well as peripheral blood lymphocyte subtypes within different subsets. To further distinguish the immune response in patients with MOGAD and GFAP-A from that of healthy individuals, we prospectively recruited 20 hospitalized patients diagnosed with AE. Among them, 15 (75%) tested positive for MOG antibodies, 4 (20%) tested positive for GFAP antibodies, and 1 (5%) tested positive for both MOG and GFAP antibodies. These patients were then followed up for a period of 18 months. Compared to healthy controls (HC), AE patients exhibited elevated levels of MIP-1beta, SDF-1alpha, IL-12p70, IL-5, IL-1RA, IL-8 and decreased levels of IL-23, IL-31, IFN-alpha, IL-7, TNF-beta and TNF-alpha in serum. The CSF of AE patients showed increased levels of IL-1RA, IL-6 and IL-2 while decreased levels of RANTES, IL-18,IL-7,TNF-beta,TNF-alpha,RANTES,Eotaxin,and IL-9. The level of MCP-1 in the CSF of GFAP-A patients was found to be lower compared to that of MOGAD patients, while RANTES levels were higher. And the levels of IL-17A, Eotaxin, GRO-alpha, IL-8, IL-1beta, MIP-1beta were higher in the CSF of patients with epilepsy. The presence of intrathecal immune responses is also observed in patients with spinal muscular atrophy (SMA). However, no biomarker was found to be associated with disease severity in patients with AE. Among the 17 patients, recovery was observed, while 2 patients experienced persistent symptoms after an 18-month follow-up period. Additionally, within one year of onset, 8 patients had a single recurrence. Therefore, the immunological profiles of MOGAD and GFAP-A patients differ from those of normal individuals, and the alterations in cytokine levels may also exhibit a causal association with the clinical presentations, such as seizure.

Brazilian consensus recommendations on the diagnosis and treatment of autoimmune encephalitis in the adult and pediatric populations

BACKGROUND

 Autoimmune encephalitis (AIE) is a group of inflammatory diseases characterized by the presence of antibodies against neuronal and glial antigens, leading to subacute psychiatric symptoms, memory complaints, and movement disorders. The patients are predominantly young, and delays in treatment are associated with worse prognosis.

OBJECTIVE

 With the support of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, ABN) and the Brazilian Society of Child Neurology (Sociedade Brasileira de Neurologia Infantil, SBNI), a consensus on the diagnosis and treatment of AIE in Brazil was developed using the Delphi method.

METHODS

 A total of 25 panelists, including adult and child neurologists, participated in the study.

RESULTS

 The panelists agreed that patients fulfilling criteria for possible AIE should be screened for antineuronal antibodies in the serum and cerebrospinal fluid (CSF) using the tissue-based assay (TBA) and cell-based assay (CBA) techniques. Children should also be screened for anti-myelin oligodendrocyte glucoprotein antibodies (anti-MOG). Treatment should be started within the first 4 weeks of symptoms. The first-line option is methylprednisolone plus intravenous immunoglobulin (IVIG) or plasmapheresis, the second-line includes rituximab and/or cyclophosphamide, while third-line treatment options are bortezomib and tocilizumab. Most seizures in AIE are symptomatic, and antiseizure medications may be weaned after the acute stage. In anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, the panelists have agreed that oral immunosuppressant agents should not be used. Patients should be evaluated at the acute and postacute stages using functional and cognitive scales, such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Modified Rankin Scale (mRS), and the Clinical Assessment Scale in Autoimmune Encephalitis (CASE).

CONCLUSION

 The present study provides tangible evidence for the effective management of AIE patients within the Brazilian healthcare system.

Autism spectrum disorder and a possible role of anti-inflammatory treatments: experience in the pediatric allergy/immunology clinic

Autism spectrum disorder (ASD1) is a behaviorally defined syndrome encompassing a markedly heterogeneous patient population. Many ASD subjects fail to respond to the 1st line behavioral and pharmacological interventions, leaving parents to seek out other treatment options. Evidence supports that neuroinflammation plays a role in ASD pathogenesis. However, the underlying mechanisms likely vary for each ASD patient, influenced by genetic, epigenetic, and environmental factors. Although anti-inflammatory treatment measures, mainly based on metabolic changes and oxidative stress, have provided promising results in some ASD subjects, the use of such measures requires the careful selection of ASD subjects based on clinical and laboratory findings. Recent progress in neuroscience and molecular immunology has made it possible to allow re-purposing of currently available anti-inflammatory medications, used for autoimmune and other chronic inflammatory conditions, as treatment options for ASD subjects. On the other hand, emerging anti-inflammatory medications, including biologic and gate-keeper blockers, exert powerful anti-inflammatory effects on specific mediators or signaling pathways. It will require both a keen understanding of the mechanisms of action of such agents and the careful selection of ASD patients suitable for each treatment. This review will attempt to summarize the use of anti-inflammatory agents already used in targeting ASD patients, and then emerging anti-inflammatory measures applicable for ASD subjects based on scientific rationale and clinical trial data, if available. In our experience, some ASD patients were treated under diagnoses of autoimmune/autoinflammatory conditions and/or post-infectious neuroinflammation. However, there are little clinical trial data specifically for ASD subjects. Therefore, these emerging immunomodulating agents for potential use for ASD subjects will be discussed based on preclinical data, case reports, or data generated in patients with other medical conditions. This review will hopefully highlight the expanding scope of immunomodulating agents for treating neuroinflammation in ASD subjects.

Treatment Approaches in Pediatric Relapsing Autoimmune Encephalitis

Purpose of review

Autoimmune encephalitis (AE) is increasingly recognized as a treatable cause of encephalitis in children. While prior observational studies demonstrate improved motor outcomes with early immunotherapy, less is known about long-term management and treatment for relapsing disease. In this review, we present current treatment approaches to pediatric AE, in particular relapse risk and treatment for relapsing AE in children.

Recent findings

A recent meta-analysis of anti-NMDAR encephalitis demonstrated that disease onset in adolescence was associated with an increased odds of relapse whereas treatment with rituximab and IVIG for 6 months or longer were associated with a non-relapsing course. However, no specific pediatric sub-analyses were reported. A single-center study on adult and pediatric AE showed that rituximab use was associated with a reduction in time to relapse and recurring relapses although the data for the pediatric cohort did not achieve statistical significance.

Summary

The use of second-line immunotherapy during the initial attack may reduce the risk for relapsing disease in pediatric AE. Larger studies are needed to investigate relapse risk and treatment in both anti-NMDAR and non-NMDAR encephalitis in children.

Therapeutic potential of natural killer cells in neuroimmunological diseases

Natural killer (NK) cells, a major component of the innate immune system, have prominent immunoregulatory, antitumor proliferation, and antiviral activities. NK cells act as a double-edged sword with therapeutic potential in neurological autoimmunity. Emerging evidence has identified NK cells are involved in the development and progression of neuroimmunological diseases such as multiple sclerosis, neuromyelitis optica spectrum disorders, autoimmune encephalitis, Guillain-Barré Syndrome, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and idiopathic inflammatory myopathy. However, the regulatory mechanisms and functional roles of NK cells are highly variable in different clinical states of neuroimmunological diseases and need to be further determined. In this review, we summarize the evidence for the heterogenic involvement of NK cells in the above conditions. Further, we describe cutting-edge NK-cell-based immunotherapy for neuroimmunological diseases in preclinical and clinical development and highlight challenges that must be overcome to fully realize the therapeutic potential of NK cells.

B-cell targeted therapies in autoimmune encephalitis: mechanisms, clinical applications, and therapeutic potential

Autoimmune encephalitis (AE) broadly refers to inflammation of the brain parenchyma mediated by autoimmune mechanisms. In most patients with AE, autoantibodies against neuronal cell surface antigens are produced by B-cells and induce neuronal dysfunction through various mechanisms, ultimately leading to disease progression. In recent years, B-cell targeted therapies, including monoclonal antibody (mAb) therapy and chimeric antigen receptor T-cell (CAR-T) therapy, have been widely used in autoimmune diseases. These therapies decrease autoantibody levels in patients and have shown favorable results. This review summarizes the mechanisms underlying these two B-cell targeted therapies and discusses their clinical applications and therapeutic potential in AE. Our research provides clinicians with more treatment options for AE patients whose conventional treatments are not effective.

Case report: Rapid recovery after intrathecal rituximab administration in refractory anti-NMDA receptor encephalitis: report of two cases

Background

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the most prevalent etiologies of autoimmune encephalitis. Approximately 25% of anti-NMDAR encephalitis cases prove refractory to both first- and second-line treatments, posing a therapeutic dilemma due to the scarcity of evidence-based data for informed decision-making. Intravenous rituximab is commonly administered as a second-line agent; however, the efficacy of its intrathecal administration has rarely been reported.

Case summary

We report two cases of severe anti-NMDAR encephalitis refractory to conventional therapies. These patients presented with acute-onset psychosis progressing to a fulminant picture of encephalitis manifesting with seizures, dyskinesia, and dysautonomia refractory to early initiation of first- and second-line therapeutic agents. Both patients received 25 mg of rituximab administered intrathecally, repeated weekly for a total of four doses, with no reported adverse effects. Improvement began 2-3 days after the first intrathecal administration, leading to a dramatic recovery in clinical status and functional performance. At the last follow-up of 6 months, both patients remain in remission without the need for maintenance immunosuppression.

Conclusion

Our cases provide evidence supporting the intrathecal administration of rituximab as a therapeutic option for patients with refractory anti-NMDAR encephalitis. Considering the limited penetration of intravenous rituximab into the central nervous system, a plausible argument can be made favoring intrathecal administration as the preferred route or the simultaneous administration of intravenous and intrathecal rituximab. This proposition warrants thorough investigation in subsequent clinical trials.

Controversies in immunotherapy for anti-NMDA receptor encephalitis: a scoping review with a proposal of operational definitions

Anti-NMDA receptor encephalitis (NMDARE), an autoimmune encephalitis associated with autoantibodies against the N-methyl-D-aspartate (NMDA) receptor, affects predominantly young women and is associated with psychiatric symptoms, seizures, movement disorders, and autonomic instability. Traditional treatments of anti-NMDA receptor encephalitis involve corticosteroids, intravenous immunoglobulin, plasmapheresis, cyclophosphamide, and rituximab. However, many controversies remain in the treatment for NMDA receptor encephalitis, such as optimal timing and combination of different immunotherapies, the role of newer strategies (e.g., bortezomib or tocilizumab) for severe and refractory patients, and the need or not for long-term immunosuppression. Our goal was to perform a scoping review to discuss the controversial topics of immunotherapy for NMDA receptor encephalitis and propose operational definitions to guide clinical practice and future research in the field.

Impact of Neurological Rehabilitation in Autoimmune Encephalopathy: A Case Report

The physiotherapy rehabilitation program aims to build up functional activity, coordination, and balance ambulation for proper independence in the activities of daily living. An uncommon but complicated neurological condition called autoimmune encephalopathy is caused by the body's immune system mistakenly attacking healthy brain tissue. This condition often leads to a wide range of neurological and cognitive symptoms, making its diagnosis and treatment challenging. Physiotherapy, a vital component of the comprehensive management of autoimmune encephalopathy, plays an important role in improving the health of affected patients. In this report, the patient's occupational requirements and enhancement in executing daily living tasks were the focus of physiotherapeutic rehabilitation. The outcomes included the Berg Balance Scale and Functional Independence Measure. We observed a marked increment in muscle tone and strength, active range of motion, and significant enhancement in the individual's functional independence with physiotherapeutic protocol postoperatively. This case report provides an overview of the execution and function of physiotherapy in the management of autoimmune encephalopathy, emphasizing its contributions to symptom alleviation, functional recovery, and the overall well-being of patients.

Targeted Treatment of Diseases of Immune Dysregulation

Increasing molecular knowledge of autoinflammatory and autoimmune disorders has enabled more targeted treatment of these conditions. Treatment of inflammasomopathies is often aimed at interleukin-1 (IL-1) blockade, with potential use of other inhibitors targeting cytokines such as IL-18 and IL-6. Interferonopathies and some disorders with overlap features of autoimmunity and autoinflammation may improve with Janus kinase inhibition. Autoimmune conditions may also respond to inhibition of different cytokines, as well as to inhibition of T and B lymphocytes. Effective treatment is increasingly possible through targeted/precision medicine approaches.

SOCS-JAK-STAT inhibitors and SOCS mimetics as treatment options for autoimmune uveitis, psoriasis, lupus, and autoimmune encephalitis

Autoimmune diseases arise from atypical immune responses that attack self-tissue epitopes, and their development is intricately connected to the disruption of the JAK-STAT signaling pathway, where SOCS proteins play crucial roles. Conditions such as autoimmune uveitis, psoriasis, lupus, and autoimmune encephalitis exhibit immune system dysfunctions associated with JAK-STAT signaling dysregulation. Emerging therapeutic strategies utilize JAK-STAT inhibitors and SOCS mimetics to modulate immune responses and alleviate autoimmune manifestations. Although more research and clinical studies are required to assess their effectiveness, safety profiles, and potential for personalized therapeutic approaches in autoimmune conditions, JAK-STAT inhibitors and SOCS mimetics show promise as potential treatment options. This review explores the action, effectiveness, safety profiles, and future prospects of JAK inhibitors and SOCS mimetics as therapeutic agents for psoriasis, autoimmune uveitis, systemic lupus erythematosus, and autoimmune encephalitis. The findings underscore the importance of investigating these targeted therapies to advance treatment options for individuals suffering from autoimmune diseases.

State of the Art: Acute Encephalitis

Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.

Effectiveness of intra-thecal methotrexate in refractory Anti-N-methyl-d-aspartate receptor encephalitis

BACKGROUND

Anti-N-methyl-d-aspartate "anti-NMDA" receptor encephalitis is one of the most common autoimmune encephalitis for which first- and second-line therapies have been recommended following international consensus. However, some refractory cases do not respond to the first- and second-line therapy and require further immune-modulatory therapies such as intra-thecal methotrexate. In this study, we reviewed six confirmed cases of refractory anti-NMDA receptor encephalitis from two tertiary centers in Saudi Arabia that required escalation of treatment and received a six-month course of intra-thecal methotrexate. The aim of this study was to evaluate the effectiveness of intra-thecal methotrexate as immunomodulatory therapy for refractory anti-NMDA receptor encephalitis.

METHODS

We retrospectively evaluated six confirmed cases of refractory anti-NMDA receptor encephalitis who did not improve after first- and second-line therapy and received monthly intra-thecal methotrexate treatment course for six consecutive months. We reviewed patient demography, underlying etiologies, and compared their modified Rankin score prior to receiving intra-thecal methotrexate and six months after completing the treatment.

RESULTS

Three of the six patients showed a marked response to intra-thecal methotrexate with a modified Rankin scale of 0-1 at 6-month follow-up. None of the patients experienced any side effects during or after intra-thecal methotrexate treatment, and no flareups were observed.

CONCLUSION

Intra-thecal methotrexate may be a potentially effective and relatively safe escalation option for immunomodulatory therapy of refractory anti-NMDA receptor encephalitis. Future studies on intra-thecal methotrexate -specific treatment regimens may further support its utility, efficacy, and safety in treating refractory anti-NMDA receptor encephalitis.

Subdural Levels of Interleukin 1-receptor Antagonist are Elevated in Patients with Recurrent Chronic Subdural Hematomas

Anti-inflammatory treatment reduces the risk of recurrent chronic subdural hematoma (CSDH), but clinical implementation is improper due to side effects. Exact knowledge of subdural molecules involved in recurrent CSDH may lead to targeted medical treatment and possibly improve the prospect of a personalized approach by eliminating the broad use of anti-inflammatory drugs on the entire CSDH population. With this study, we aim to (1) describe the associations between cytokine levels at the primary surgery and the risk of subsequent recurrence and (2) describe the association between cytokines in patients with recurrent CSDH between the first and second operations. Systemic and subdural levels of pro- and anti-inflammatory cytokines were measured and compared between patients with the first-time CSDH and recurrent CSDH. Cytokine levels were analyzed using a multiplex antibody bead kit. In case of recurrent CSDH within 90 days of follow-up, the samples were re-collected and analyzed. We included 101 adult CSDH patients of which 20 had a recurrence. The levels of cytokines in the CSDH fluid from patients who were operated on for the first-time CSDH were not associated with the risk of later developing a recurrence. We found interleukin-1 receptor antagonist (IL-1ra) to be elevated in subdural fluid in patients with recurrent CSDH at the time of their second operation (p = 0.0005). This study provides knowledge on cytokine composition in the subdural fluid in patients with CSDH with and without recurrence. IL-1ra is elevated in subdural fluid in patients with recurrent CSDH at the time of the second operation, identifying a possible medical target.

Autoimmune encephalitis: Epidemiology, pathophysiology and clinical spectrum (part 2)

Autoimmune encephalitis (AE) represents a growing number of severe autoimmune-inflammatory diseases affecting both the white and grey matter of the brain. In part 1 of this series we focused on the epidemiology, pathophysiology and clinical presentation of this condition, with two illustrative cases. In this part, we will introduce the clinical criteria for AE, particularly for the diagnosis of anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, which were developed to facilitate immune treatment in suspected cases before antibody results are available. We subsequently discuss the work up, differential diagnosis and treatment options for patients with this disease.  

Cerebellar involvement associated with immune checkpoint inhibitors: A systematic review

BACKGROUND AND PURPOSE

Immune checkpoint inhibitors (ICIs) targeting programmed death receptor 1 (PD-1), cytotoxic T-lymphocyte-associated-4 (CTLA-4) and programmed cell death ligand 1 can be associated with immune-related adverse events (iRAEs). Amongst neurological iRAEs, cerebellar involvement seems to be rare and currently lacks a proper characterization. The aim of this study was to phenotype cerebellar iRAEs.

METHODS

A systematic review was performed according to PRISMA guidelines including reported patients with cerebellar involvement related to ICIs and with available individual data.

RESULTS

After screening 2765 records, 32 studies with 46 patients were included. Median age was 63 years (20-82), and most patients were male (63.0%). Isolated cerebellitis was observed in 32.6% of cases, whilst the remaining cases had "cerebellitis plus", mostly associated with encephalitis/encephalopathy. Associated tumors included most frequently lung cancer, melanoma and Merkel cell carcinoma. PD-1 inhibitor was the most administered treatment (n = 29, 64.4%), whilst exposure to CTLA-4 inhibitor was rare (n = 2, 4.5%). Magnetic resonance imaging was abnormal in 43.2% of patients and inflammatory cerebrospinal fluid findings were frequently observed. Autoantibodies were detected in 61.9% of patients and included novel reactivities. Amongst treatment strategies, the most common were steroids (n = 36) and ICI discontinuation (n = 28, 90.3%). Relapses were reported in 10% of patients. Most patients showed improvement/remission (n = 31) but, at last follow-up, 12 had died. Isolated cerebellitis versus cerebellitis-plus differed in terms of outcomes, whilst seropositive versus seronegative patients had distinct tumor associations.

DISCUSSION

Cerebellar iRAEs are usually multifocal, have heterogeneous tumor associations, are most associated with PD-1 inhibitor exposure and are related to autoantibodies, including novel reactivities.