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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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Decoux-Poullot AG, Bannwarth S, Procaccio V, Lebre AS, Jardel C, Vialettes B, Paquis-Flucklinger V, Chevalier N. Clinical phenotype of mitochondrial diabetes due to rare mitochondrial DNA mutations. ANNALES D'ENDOCRINOLOGIE 2020; 81:68-77. [PMID: 32409007 DOI: 10.1016/j.ando.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE While the most frequent mutation responsible for mitochondrial diabetes is the point mutation m.3243 A>G of mitochondrial DNA (mtDNA), few data are available about the role of rare mtDNA mutations in the pathophysiology of diabetes. The main objective of our study was to describe the phenotypic characteristics of patients suffering from diabetes linked to rare mtDNA mutations. RESEARCH DESIGN AND METHODS We performed a post-hoc analysis of a prospective multicenter cohort of 743 patients with mitochondrial disorder (previously published by the French Network of Mitochondrial Diseases), associated to a literature review of the PubMed database from 1992 to May 2016. We extracted all reported patients with diabetes and identified rare mtDNA mutations and described their clinical and metabolic phenotypes. RESULTS The 50 identified patients (10 from the princeps study; 40 from the review of the literature) showed a heterogeneous metabolic phenotype in terms of age, symptoms prior to diagnosis, treatments, and associated clinical and biological signs. However, neurological symptoms were more frequent in case of rare mtDNA mutations compared to the classical m.3243 A>G mutation (P=0.024). In contrast, deafness (65% vs. 95%, P=3.7E-5), macular pattern dystrophy (20% vs. 86%, P=1.6E-10) and nephropathy (8% vs. 28%, P=0.018) were significantly less frequent than in case of the classical m.3243 A>G mutation. CONCLUSION Although no specific metabolic phenotype could be identified suggesting or eliminating implication of rare mtDNA mutations in diabetes, clinical phenotypes featured more frequent neurological signs.
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Affiliation(s)
- Anne-Gaëlle Decoux-Poullot
- Service d'endocrinologie, diabétologie et médecine de la reproduction, hôpital de l'Archet 2, université Côte d'Azur, CHU de Nice, Nice, France
| | - Sylvie Bannwarth
- Inserm, CNRS, IRCAN, Université Côte d'Azur, CHU de Nice, Nice, France
| | | | - Anne-Sophie Lebre
- Inserm U781, Service de génétique, Hôpital Necker-Enfants-Malades, Université Paris-Descartes, Paris, France
| | - Claude Jardel
- Biochimie métabolique, Centre de génétique moléculaire et chromosomique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Bernard Vialettes
- Service d'endocrinologie, diabète, maladies métaboliques, Hôpital de la Conception, CHU de Marseille, 13385 Marseille Cedex 5, France
| | | | - Nicolas Chevalier
- Service d'endocrinologie, diabétologie et médecine de la reproduction, hôpital de l'Archet 2, université Côte d'Azur, CHU de Nice, Nice, France; Institut national de la santé et de la recherche médicale (Inserm), UMR U1065/UNS, Centre méditerranéen de médecine moléculaire (C3M), équipe 5 « Cellular Basis and Signaling of Tumor Metabolism », Université Côte d'Azur, CHU de Nice, Nice, France.
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Frunza-Stefan S, Whitlatch HB, Rao GG, Malek R. Unusual case of anti-N-methyl-D-aspartic acid-receptor (NMDA-R) encephalitis and autoimmune polyglandular syndrome (APS). BMJ Case Rep 2018; 2018:bcr-2018-224821. [PMID: 29724875 PMCID: PMC5935153 DOI: 10.1136/bcr-2018-224821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 01/06/2023] Open
Abstract
Anti-N-methyl-D-aspartic acid-receptor (NMDA-R) encephalitis is a novel disease discovered within the past 10 years. It is an autoimmune disease (AD) that has been associated with other ADs, such as Graves' disease. However, association with autoimmune polyglandular syndromes (APS) has not been previously described. A 58-year-old woman presented with altered mental status and an 8-month history of weight loss, apathy and somnolence. Laboratory evaluation confirmed Graves' disease with thyrotoxicosis and type 1 diabetes mellitus. Despite treatment, she continued to have a fluctuating mental status. Further diagnostic evaluation included an abdominal MRI that showed a cystic lobular left adnexal mass. Serum anti-NMDA-R antibodies were positive, raising concern for NMDA-R encephalitis. Bilateral salpingo-oophorectomy was performed, with pathology consistent with cystadenofibroma. She had a favourable recovery with marked clinical improvement. Anti-NMDA-R antibodies were negative 2 months following surgery. The concomitant occurrence of APS and anti-NMDA-R encephalitis suggests a shared mechanism of autoimmune pathophysiology.
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Affiliation(s)
- Simona Frunza-Stefan
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Hilary B Whitlatch
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Gautam G Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Rana Malek
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
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Fredriksen JR, Carr CM, Koeller KK, Verdoorn JT, Gadoth A, Pittock SJ, Kotsenas AL. MRI findings in glutamic acid decarboxylase associated autoimmune epilepsy. Neuroradiology 2018; 60:239-245. [PMID: 29353399 DOI: 10.1007/s00234-018-1976-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/03/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Glutamic acid decarboxylase (GAD65) has been implicated in a number of autoimmune-associated neurologic syndromes, including autoimmune epilepsy. This study categorizes the spectrum of MRI findings in patients with a clinical diagnosis of autoimmune epilepsy and elevated serum GAD65 autoantibodies. METHODS An institutional database search identified patients with elevated serum GAD65 antibodies and a clinical diagnosis of autoimmune epilepsy who had undergone brain MRI. Imaging studies were reviewed by three board-certified neuroradiologists and one neuroradiology fellow. Studies were evaluated for cortical/subcortical and hippocampal signal abnormality, cerebellar and cerebral volume loss, mesial temporal sclerosis, and parenchymal/leptomeningeal enhancement. The electronic medical record was reviewed for relevant clinical information and laboratory markers. RESULTS A study cohort of 19 patients was identified. The majority of patients were female (84%), with a mean age of onset of 27 years. Serum GAD65 titers ranged from 33 to 4415 nmol/L (normal < 0.02 nmol/L). The most common presentation was medically intractable, complex partial seizures with temporal lobe onset. Parenchymal atrophy was the most common imaging finding (47%), with a subset of patients demonstrating cortical/subcortical parenchymal T2 hyperintensity (37%) or abnormal hippocampal signal (26%). No patients demonstrated abnormal parenchymal/leptomeningeal enhancement. CONCLUSION The most common MRI finding in GAD65-associated autoimmune epilepsy is disproportionate parenchymal atrophy for age, often associated with abnormal cortical/subcortical T2 hyperintensities. Hippocampal abnormalities are seen in a minority of patients. This constellation of findings in a patient with medically intractable epilepsy should raise the possibility of GAD65 autoimmunity.
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Affiliation(s)
- Jason R Fredriksen
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Kelly K Koeller
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Avi Gadoth
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Amy L Kotsenas
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Manto M, Hampe CS. Endocrine disorders and the cerebellum: from neurodevelopmental injury to late-onset ataxia. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:353-368. [PMID: 29891071 DOI: 10.1016/b978-0-444-64189-2.00023-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hormonal disorders are a source of cerebellar ataxia in both children and adults. Normal development of the cerebellum is critically dependent on thyroid hormone, which crosses both the blood-brain barrier and the blood-cerebrospinal fluid barrier thanks to specific transporters, including monocarboxylate transporter 8 and the organic anion-transporting polypeptide 1C1. In particular, growth and dendritic arborization of Purkinje neurons, synaptogenesis, and myelination are dependent on thyroid hormone. Disturbances of thyroid hormone may also impact on cerebellar ataxias of other origin, decompensating or aggravating the pre-existing ataxia manifesting with motor ataxia, oculomotor ataxia, and/or Schmahmann syndrome. Parathyroid disorders are associated with a genuine cerebellar syndrome, but symptoms may be subtle. The main conditions combining diabetes and cerebellar ataxia are Friedreich ataxia, ataxia associated with anti-GAD antibodies, autoimmune polyglandular syndromes, aceruloplasminemia, and cerebellar ataxia associated with hypogonadism (especially Holmes ataxia/Boucher-Neuhäuser syndrome). The general workup of cerebellar disorders should include the evaluation of hormonal status, including thyroid-stimulating hormone and free thyroxine levels, and hormonal replacement should be considered depending on the laboratory results. Cerebellar deficits may be reversible in some cases.
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Affiliation(s)
- Mario Manto
- Neurology Service, CHU-Charleroi, Charleroi, Belgium; Neuroscience Service, Université de Mons, Mons, Belgium.
| | - Christiane S Hampe
- Department of Medicine, University of Washington, Seattle, United States
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Haitao R, Huiqin L, Tao Q, Xunzhe Y, Xiaoqiu S, Wei L, Jiewen Z, Liying C, Hongzhi G. Autoimmune encephalitis associated with vitiligo? J Neuroimmunol 2017; 310:14-16. [DOI: 10.1016/j.jneuroim.2017.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/26/2023]
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Baizabal-Carvallo JF, Alonso-Juarez M. Cerebellar disease associated with anti-glutamic acid decarboxylase antibodies: review. J Neural Transm (Vienna) 2017; 124:1171-1182. [PMID: 28689294 DOI: 10.1007/s00702-017-1754-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 07/03/2017] [Indexed: 12/28/2022]
Abstract
Several neurological syndromes have been recognized associated to GAD antibodies. Among those disorders, cerebellar ataxia (CA) is one of the most common, along with stiff-person syndrome. Patients with GAD associated CA present with a progressive pancerebellar syndrome, with a subacute or chronic evolution, along with other neurological manifestations such as stiffness, oculomotor dysfunction, epilepsy, and cognitive dysfunction. These symptoms may be preceded by the so-called "brainstem attacks", where manifestations consistent with transient dysfunction of the brainstem may be observed. These patients frequently have extra-neurologic autoimmune manifestations such as diabetes mellitus type 1, polyendocrine autoimmune syndrome, pernicious anemia, vitiligo, etc. A proportion of patients may present with an underlying neoplasia, but the course is less aggressive than in those patients with classical paraneoplastic CA with onconeural antibodies. The diagnosis is based on the present of high serum and CSF titers of GAD antibodies, with intrathecal production of such antibodies. Treatment is aimed to decrease the immunological response with intravenous immunoglobulin, steroids, rituximab and oral immunosuppressive drugs. A subacute presentation and rapid initiation of immunotherapy seem to be the predictors of a favorable clinical response.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, TX, USA.
- Department of Internal Medicine, University of Guanajuato, 20 de Enero no. 927, C.P. 37320, León, Guanajuato, Mexico.
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Petrijan T, Menih M. Low-Titre GAD Antibody-Associated Late-Onset Cerebellar Ataxia with a Significant Clinical Response to Intravenous Immunoglobulin Treatment. CEREBELLUM (LONDON, ENGLAND) 2017; 16:868-871. [PMID: 28321713 DOI: 10.1007/s12311-017-0851-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Antiglutamic acid decarboxylase antibody-associated cerebellar ataxia (GAD-Abs CA) is a rare, but increasingly detected, autoimmune neurological disorder characterized by the clinical presence of a cerebellar syndrome concomitant with positive GAD-Abs levels in serum and cerebrospinal fluid (CSF). It represents 3% of all immune-mediated sporadic CAs. Low-titre GAD-Abs CA is an even rarer subtype of GAD-Abs CA. We report on a 68-year-old woman with a 3-year history of progressive gait ataxia. In addition to the modified Rankin Scale (mRS), we used two other objective scales to evaluate CA severity, i.e. the International Cooperative Ataxia Rating Scale (ICARS) and the Scale for Assessment and Rating of Ataxia (SARA). Series of CT and MRI showed atrophy of the cerebellum. Except for the glycated haemoglobin (HbA1c) levels, all other routine laboratory examinations were within normal limits. Autoimmune laboratory examinations showed positive (25.8 U/mL) serum GAD-Abs levels. The GAD antibody index was <1.0. The CSF analysis showed no oligoclonal immunoglobulin bands. Intravenous immunoglobulin (IVIg) therapy was started and significant improvement was observed. The diagnosis of low-titre GAD-Abs CA was established.
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Affiliation(s)
- Timotej Petrijan
- Department of Neurology, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia.
| | - Marija Menih
- Department of Neurology, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
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Pathogenic Roles of Glutamic Acid Decarboxylase 65 Autoantibodies in Cerebellar Ataxias. J Immunol Res 2017; 2017:2913297. [PMID: 28386570 PMCID: PMC5366212 DOI: 10.1155/2017/2913297] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/05/2016] [Accepted: 01/10/2017] [Indexed: 12/12/2022] Open
Abstract
Reports suggesting a pathogenic role of autoantibodies directed against glutamic acid decarboxylase 65 (GAD65Abs) in cerebellar ataxias (CAs) are reviewed, and debatable issues such as internalization of antibodies by neurons and roles of epitopes are discussed. GAD65 is one of two enzymes that catalyze the conversion of glutamate to the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). A pathogenic role of GAD65Ab in CAs is suggested by in vivo and in vitro studies. (1) Intracerebellar administration of cerebrospinal fluid (CSF) immunoglobulins (IgGs) obtained from GAD65Ab-positive CA patients impairs cerebellar modulation of motor control in rats. (2) CSF IgGs act on terminals of GABAergic neurons and decrease the release of GABA in cerebellar slices from rats and mice. (3) Absorption of GAD65Ab by recombinant GAD65 diminishes the above effects, and monoclonal human GAD65Ab (b78) mimic the effects of CSF IgGs in vivo and in vitro. Studies using GAD65-KO mice confirm that the target molecule is GAD65. (4) Notably, the effects of GAD65Ab depend on the epitope specificity of the monoclonal GAD65Ab. Taken together, these results indicate that epitope-specific GAD65Ab-induced impairment of GABA release is involved in the pathogenesis of GAD65Ab-positive CA and support the early detection of GAD65Ab-associated CA to initiate immunotherapy before irreversible neuronal death in the cerebellum.
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Flores-Cantu H, Camara-Lemarroy CR, Calderon-Hernandez HJ, Zapata-Rivera MA, Villareal-Perez JZ, Villareal-Velazquez HJ. Anti-GAD Antibody, Seizures, Cerebellar Ataxias and Vitiligo: A Diagnostic Challenge. THE CEREBELLUM 2016; 14:375-7. [PMID: 25575726 DOI: 10.1007/s12311-014-0625-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Hazael Flores-Cantu
- Servicio de Neurologia, Hospital Universitario "Dr. José E. González". Universidad Autónoma de Nuevo León, Madero y Gonzalitos S/N, 64460, Monterrey, NL, Mexico
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Martínez Zapico A, Martínez Rodríguez L, Morís de la Tassa G, Caminal Montero L. Encefalitis límbica: una entidad hasta ahora poco conocida. Med Clin (Barc) 2016; 146:465-6. [DOI: 10.1016/j.medcli.2015.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/14/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
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Abstract
Ataxia is a disorder of balance and coordination resulted from dysfunctions involving cerebellum and its afferent and efferent connections. While a variety of disorders can cause secondary ataxias, the list of genetic causes of ataxias is growing longer. Genetic abnormalities may involve mitochondrial dysfunction, oxidative stress, abnormal mechanisms of DNA repair, possible protein misfolding, and abnormalities in cytoskeletal proteins. Few ataxias are fully treatable while hope for efficacious gene therapy and pharmacotherapy is emerging. A discussion of the ataxias is presented here with brief mention of acquired ataxias, and a greater focus on inherited ataxias.
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Affiliation(s)
- Umar Akbar
- Department of Neurology, Center for Movement Disorders and Neurorestoration College of Medicine, McKnight Brain Institute, University of Florida, 1149 South Newell Drive, L3-100, Gainesville, FL 32611, USA
| | - Tetsuo Ashizawa
- Department of Neurology, Center for Movement Disorders and Neurorestoration College of Medicine, McKnight Brain Institute, University of Florida, 1149 South Newell Drive, L3-100, Gainesville, FL 32611, USA.
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Farooq AV, Soin K, Moss HE. Alternating skew deviation in association with anti-glutamic acid decarboxylase antibodies. Neuroophthalmology 2015; 39:140-143. [PMID: 26594078 DOI: 10.3109/01658107.2015.1011755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The presence of an elevated anti-glutamic acid decarboxylase (GAD) antibody level has been associated with a number of eye movement abnormalities, as well as other findings including cerebellar ataxia and insulin dependent diabetes mellitus. Skew deviation in association with anti-GAD antibodies has not been previously reported. Here we report a case of alternating skew deviation along with cerebellar-brainstem signs in a patient with an elevated anti-GAD antibody titer. Follow-up neurologic evaluation after treatment with intravenous immunoglobulin revealed improvement in cerebellar-brainstem signs, while ophthalmic evaluation was stable.
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Affiliation(s)
- Asim V Farooq
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ketki Soin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Heather E Moss
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
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Haller-Kikkatalo K, Pruul K, Kisand K, Nemvalts V, Reimand K, Uibo R. GADA and anti-ZnT8 complicate the outcome of phenotypic type 2 diabetes of adults. Eur J Clin Invest 2015; 45:255-62. [PMID: 25611374 DOI: 10.1111/eci.12404] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/17/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND A proportion of phenotypic type 2 diabetes (T2D) patients produce pancreatic autoantibodies and a majority of T2D patients develop serious life-disabling complications over time despite the implementation of adequate clinical interventions. This study determined whether the presence of pancreatic autoantibodies (GADA, IA-2A, anti-ZnT8, or ICA) was associated with serious complications or concomitant diseases of adult patients diagnosed with T2D (N = 305). MAIN RESULTS In the study population, 22.3% (N = 68) of subjects were positive for at least 1 of the 4 of the markers associated with autoimmune diabetes (presence of pancreatic autoantibody - pAb), followed by GADA (14.1%, N = 43), ICA (8.9%, N = 27), anti-ZnT8 (5.6%, N = 17) and IA-2A (2.0%, N = 6). Logistic regression analysis adjusted for patient's age, gender and duration of T2D revealed that (i) pAb was associated with higher prevalence of adiposity (odds ratio of adjusted regression model (adOR) 2.51, P = 0.032); (ii) pAb, GADA and anti-ZnT8 were associated with autoimmune thyroid disease (adORs 3.07, P = 0.012; 6.29, P < 0.001 and 3.52, P = 0.052, respectively); (iii) pAb and GADA, in particular, were risk factors for neurological complications (adORs 2.10, P = 0.036; 2.76, P = 0.009, respectively) and polyneuropathy in particular (adORs 2.60, P = 0.012; 3.10, P = 0.007, respectively); and (iv) anti-ZnT8 was a risk factor for developing nephropathy (adOR 4.61, P = 0.022). In addition, adiposity was associated with 5.3-year earlier onset of disease (adjusted linear regression model, P = 0.006). CONCLUSIONS These results suggest that GADA and anti-ZnT8 are associated with progression of serious T2D complications, including polyneuropathy and nephropathy. In addition, adiposity represents a significant risk for autoimmunity development in T2D patients.
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Affiliation(s)
- Kadri Haller-Kikkatalo
- Department of Immunology, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia; Competence Centre on Health Technologies, Tartu, Estonia; Department of Obstetrics and Gynecology, University of Tartu, Tartu, Estonia
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Ariño H, Gresa-Arribas N, Blanco Y, Martínez-Hernández E, Sabater L, Petit-Pedrol M, Rouco I, Bataller L, Dalmau JO, Saiz A, Graus F. Cerebellar ataxia and glutamic acid decarboxylase antibodies: immunologic profile and long-term effect of immunotherapy. JAMA Neurol 2014; 71:1009-16. [PMID: 24934144 DOI: 10.1001/jamaneurol.2014.1011] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Current clinical and immunologic knowledge on cerebellar ataxia (CA) with glutamic acid decarboxylase 65 antibodies (GAD65-Abs) is based on case reports and small series with short-term follow-up data. OBJECTIVE To report the symptoms, additional antibodies, prognostic factors, and long-term outcomes in a cohort of patients with CA and GAD65-Abs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study and laboratory investigations at a center for autoimmune neurologic disorders among 34 patients with CA and GAD65-Abs, including 25 with long-term follow-up data (median, 5.4 years; interquartile range, 3.1-10.3 years). MAIN OUTCOMES AND MEASURES Analysis of clinicoimmunologic features and predictors of response to immunotherapy. Immunochemistry on rat brain, cultured neurons, and human embryonic kidney cells expressing GAD65, GAD67, α1-subunit of the glycine receptor, and a repertoire of known cell surface autoantigens were used to identify additional antibodies. Twenty-eight patients with stiff person syndrome and GAD65-Abs served as controls. RESULTS The median age of patients was 58 years (range, 33-80 years); 28 of 34 patients (82%) were women. Nine patients (26%) reported episodes of brainstem and cerebellar dysfunction or persistent vertigo several months before developing CA. The clinical presentation was subacute during a period of weeks in 13 patients (38%). Nine patients (26%) had coexisting stiff person syndrome symptoms. Systemic organ-specific autoimmunities (type 1 diabetes mellitus and others) were present in 29 patients (85%). Twenty of 25 patients with long-term follow-up data received immunotherapy (intravenous immunoglobulin in 10 and corticosteroids and intravenous immunoglobulin or other immunosuppressors in 10), and 7 of them (35%) improved. Predictors of clinical response included subacute onset of CA (odds ratio [OR], 0.50; 95% CI, 0.25-0.99; P = .047) and prompt immunotherapy (OR, 0.98; 95% CI, 0.96-0.99; P = .01). Similar frequencies of serum GAD67-Abs were found in patients with CA (24 of 34 patients [71%]) and in patients with stiff person syndrome (20 of 28 patients [71%]). However, GAD67-Abs were found in all of the cerebrospinal fluid samples examined (22 samples from patients with CA and 17 samples from patients with stiff person syndrome). Glycine receptor antibodies but not other cell surface antibodies were identified in 4 patients with CA. The presence of glycine receptor antibodies did not correlate with any specific clinical feature. CONCLUSIONS AND RELEVANCE In patients with CA and GAD65-Abs, subacute onset of symptoms and prompt immunotherapy are associated with good outcome. Persistent vertigo or brainstem and cerebellar episodes can herald CA and should lead to GAD65-Ab testing, particularly in patients with systemic organ-specific autoimmunities.
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Affiliation(s)
- Helena Ariño
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Nuria Gresa-Arribas
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Yolanda Blanco
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Lidia Sabater
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Mar Petit-Pedrol
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Idoia Rouco
- Neurology Service, Department of Neurosciences, Cruces University Hospital, University of the Basque Country, Bizkaia, Spain
| | - Luis Bataller
- Neurology Service, University Hospital Politècnic La Fe, Valencia, Spain
| | - Josep O Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain5Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain6Department of Neurology, University of Pennsylvania, Philadelp
| | - Albert Saiz
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Francesc Graus
- Neurology Service, Hospital Clínic, Barcelona, Spain2Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Hampe CS, Maitland ME, Gilliam LK, Phan THT, Sweet IR, Radtke JR, Bota V, Ransom BR, Hirsch IB. High titers of autoantibodies to glutamate decarboxylase in type 1 diabetes patients: epitope analysis and inhibition of enzyme activity. Endocr Pract 2014; 19:663-8. [PMID: 23512385 DOI: 10.4158/ep12318.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Autoantibodies to glutamate decarboxylase (GAD65Ab) are found in patients with autoimmune neurological disorders or type 1 diabetes. The correct diagnosis of GAD65Ab-associated neurological disorders is often delayed by the variability of symptoms and a lack of diagnostic markers. We hypothesized that the frequency of neurological disorders with high GAD65Ab titers is significantly higher than currently recognized. METHODS We analyzed GAD65Ab titer, GAD65 enzyme activity inhibition, and GAD65Ab epitope pattern in a cohort of type 1 diabetes patients (n = 100) and correlated our findings with neurological symptoms and diseases. RESULTS Overall, 43% (43/100) of patients had detectable GAD65Ab titers (median = 400 U/mL, range: 142-250,000 U/mL). The GAD65Ab titers in 10 type 1 diabetes patients exceeded the 90th percentile of the cohort (2,000-250,000 U/mL). Sera of these 10 patients were analyzed for their GAD65Ab epitope specificity and their ability to inhibit GAD65 enzyme activity in vitro. GAD65Ab of 5 patients inhibited the enzyme activity significantly (by 34-55%). Three patients complained of muscle stiffness and pain, which was documented in 2 of these patients. CONCLUSIONS Based on our findings, we suggest that neurological disorders with high GAD65Ab titers are more frequent in type 1 diabetes patients than currently recognized.
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Affiliation(s)
- Christiane S Hampe
- Department of Medicine, University of Washington, Seattle, Washington 98109, USA.
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Current literature in diabetes. Diabetes Metab Res Rev 2009; 25:i-xii. [PMID: 19405078 DOI: 10.1002/dmrr.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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