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Zhang W, Cao W, Tao W, Wang Y, Tangzhu C, Shen Q, Shi X. Anti-NMDAR encephalitis in a child with long impaired consciousness and persistent antibodies: a case report and mini review. Front Immunol 2024; 15:1402523. [PMID: 38863715 PMCID: PMC11165090 DOI: 10.3389/fimmu.2024.1402523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/14/2024] [Indexed: 06/13/2024] Open
Abstract
We described a challenging case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in a young girl. Despite enduring months of reduced consciousness with ongoing antibody presence, she ultimately exhibited remarkable improvement within a 5-year follow-up period. Additionally, we conducted a concise review of relevant literature on anti-NMDAR encephalitis, with a specific focus on anti-NMDAR antibodies. Our findings enhance the clinical comprehension of anti-NMDAR encephalitis and offer valuable insights to clinicians for its management.
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Affiliation(s)
| | | | | | | | | | | | - Xulai Shi
- Department of Pediatric Neurology, The Second Affiliated Hospital & Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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2
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Maaloul M, Mejdoub S, Sakka S, Hachicha H, Dammak M, Koubaa F, Mhiri C, Masmoudi H, Feki S. Infrequent patterns in cerebrospinal fluid isofocusing test: Clinical significance and contribution of IgG index and Reiber diagram to their interpretation. Mult Scler Relat Disord 2024; 84:105509. [PMID: 38422634 DOI: 10.1016/j.msard.2024.105509] [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: 09/25/2023] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 03/02/2024]
Abstract
Cerebrospinal fluid (CSF) isoelectrofocusing (IEF) is considered as the gold standard for detecting an intrathecal synthesis of IgG, which is a hallmark of multiple sclerosis (MS). This corresponds to the presence of CSF-restricted IgG oligoclonal bands (OCB) (typically type 2 pattern). Moreover, this technique can also detect a systemic immune reaction with passive transfer of IgG (type 3 and 4 patterns) for which the clinical relevance is less understood. The aim of our study was to determine the frequency and disease associations of IEF type 3 and 4 patterns and to investigate the potential usefulness of including quantitative data (IgG index and Reiber Diagram) in interpreting such IEF profiles. Among 544 patients who underwent CSF IEF (Hydragel CSF isofocusing kit, Sebia®, France) in our Laboratory during a six-year-period, those who presented type 3 or 4 patterns were selected. Clinical data and results of other immunological tests were analyzed for 27 patients followed in the Neurological Department. Frequencies of type 3 and type 4 patterns were relatively low (2.3 % and 3.4 % respectively). Among patients with type 3 pattern included in our study (n = 10), 5 were diagnosed with MS. For the 5 other patients, the diagnosis was a clinically isolated syndrome (CIS) (2 cases), a probable auto-immune encephalitis (2 cases) and a possible genetic neurodegenerative disease (1 case). MS patients had an IgG index >0.7 and fell into area 4 of Reiber diagram while non-MS patients had an IgG index <0.7 and fell into area 1, except the last case. Regarding type 4 pattern (n = 17), the diagnoses were as follows: MS (3), CIS (4), Neuromyelitis optica spectrum disorders with positive anti-AQP4 antibodies (3) and anti-NMDAR autoimmune encephalitis (1). The remaining cases had central nervous system impairment related to vascular, metabolic or tumoral etiologies (3) or peripheral nervous system impairment (3). In this group (type 4 pattern), IgG index was <0.7 in 15/17 cases. Interpretation using Reiber diagram showed an abnormal blood-brain barrier for 8/17 patients. Type 3 and 4 IEF patterns are infrequently observed in routine neurology practice. It is important for the diagnostic laboratory professional as well as for the neurologist to understand their clinical relevance. Our findings highlight the contribution of quantitative evaluation of CSF (IgG index, Reiber diagram) for the interpretation of such situations. Despite the small size of our study population, our results emphasize the importance of reporting the exact type of IEF pattern and not only the positivity or not of OCB.
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Affiliation(s)
- Mouna Maaloul
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Sabrina Mejdoub
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia.
| | - Salma Sakka
- Neurology Department, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Hend Hachicha
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Mariem Dammak
- Neurology Department, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Faten Koubaa
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Chokri Mhiri
- Neurology Department, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Hatem Masmoudi
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Sawsan Feki
- Immunology Laboratory, Habib Bourguiba University Hospital, University of Sfax, Tunisia
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Vaisvilas M, Petrosian D, Bagdonaite L, Taluntiene V, Kralikiene V, Daugelaviciene N, Neniskyte U, Kaubrys G, Giedraitiene N. Seroprevalence of neuronal antibodies in diseases mimicking autoimmune encephalitis. Sci Rep 2024; 14:5352. [PMID: 38438516 PMCID: PMC10912693 DOI: 10.1038/s41598-024-55995-6] [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: 09/18/2023] [Accepted: 02/29/2024] [Indexed: 03/06/2024] Open
Abstract
Detection of neuronal antibodies for autoimmune encephalitis and paraneoplastic neurological syndromes relies on commercially available cell-based assays and lineblots. However, lineblots may reveal the presence of neuronal antibodies in patients with various non-autoimmune etiologies. Herein we describe patients with non-autoimmune etiologies (cohort B) and detectable neuronal antibodies and compare them to definite cases of autoimmune encephalitis (cohort A) for differences in clinical data. All patients positive for at least one neuronal antibody were retrospectively evaluated for autoimmune encephalitis and/or paraneoplastic neurological syndrome between 2016 and 2022. 39 cases in cohort B and 23 in cohort A were identified. In cohort B, most common diagnoses were neurodegenerative disorders in 9/39 (23.1%), brain tumors in 6/39 (15.4%) while most common detected antibodies were anti-titin (N10), anti-recoverin (N11), anti-Yo (N8) and all were detected in serum only. Differential aspects between cohort A and B were CSF pleocytosis (14/23 (60.8%) vs 11/35 (31.4%), p = 0.042, respectively), MRI features suggestive of encephalitis (6/23 (26.1%) vs 0 (0%), p = 0.002, respectively) and epilepsy restricted to temporal lobes (14/23 (60.9%) vs 2/30 (6.7%), p = 0.0003, respectively). A large proportion of lineblot results were non-specific when only serum was tested and were frequently found in non-autoimmune neurological conditions.
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Affiliation(s)
- Mantas Vaisvilas
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.
- Department of Neurology, Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08661, Vilnius, Lithuania.
| | | | - Loreta Bagdonaite
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Vera Taluntiene
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Viktorija Kralikiene
- Institute of Biosciences, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Neringa Daugelaviciene
- VU LSC-EMBL Partnership for Genome Editing Technologies, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Urte Neniskyte
- Institute of Biosciences, Life Sciences Center, Vilnius University, Vilnius, Lithuania
- VU LSC-EMBL Partnership for Genome Editing Technologies, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Natasa Giedraitiene
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [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: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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Satyadev N, Tipton PW, Martens Y, Dunham SR, Geschwind MD, Morris JC, Brier MR, Graff-Radford NR, Day GS. Improving Early Recognition of Treatment-Responsive Causes of Rapidly Progressive Dementia: The STAM 3 P Score. Ann Neurol 2024; 95:237-248. [PMID: 37782554 PMCID: PMC10841446 DOI: 10.1002/ana.26812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVE To improve the timely recognition of patients with treatment-responsive causes of rapidly progressive dementia (RPD). METHODS A total of 226 adult patients with suspected RPD were enrolled in a prospective observational study and followed for up to 2 years. Diseases associated with RPD were characterized as potentially treatment-responsive or non-responsive, referencing clinical literature. Disease progression was measured using Clinical Dementia Rating® Sum-of-Box scores. Clinical and paraclinical features associated with treatment responsiveness were assessed using multivariable logistic regression. Findings informed the development of a clinical criterion optimized to recognize patients with potentially treatment-responsive causes of RPD early in the diagnostic evaluation. RESULTS A total of 155 patients met defined RPD criteria, of whom 86 patients (55.5%) had potentially treatment-responsive causes. The median (range) age-at-symptom onset in patients with RPD was 68.9 years (range 22.0-90.7 years), with a similar number of men and women. Seizures, tumor (disease-associated), magnetic resonance imaging suggestive of autoimmune encephalitis, mania, movement abnormalities, and pleocytosis (≥10 cells/mm3 ) in cerebrospinal fluid at presentation were independently associated with treatment-responsive causes of RPD after controlling for age and sex. Those features at presentation, as well as age-at-symptom onset <50 years (ie, STAM3 P), captured 82 of 86 (95.3%) cases of treatment-responsive RPD. The presence of ≥3 STAM3 P features had a positive predictive value of 100%. INTERPRETATION Selected features at presentation reliably identified patients with potentially treatment-responsive causes of RPD. Adaptation of the STAM3 P screening score in clinical practice may minimize diagnostic delays and missed opportunities for treatment in patients with suspected RPD. ANN NEUROL 2024;95:237-248.
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Affiliation(s)
- Nihal Satyadev
- Mayo Clinic Florida, Department of Neurology; Jacksonville, FL
- Georgia Institute of Technology, Atlanta, GA
| | - Philip W Tipton
- Mayo Clinic Florida, Department of Neurology; Jacksonville, FL
| | - Yuka Martens
- Mayo Clinic Florida, Department of Neuroscience; Jacksonville, FL
| | - S Richard Dunham
- Washington University School of Medicine, Department of Neurology, Saint Louis, MO
| | - Michael D Geschwind
- University of California San Francisco, Department of Neurology, Memory and Aging Center, San Francisco, CA
| | - John C Morris
- Washington University School of Medicine, Department of Neurology, Saint Louis, MO
| | - Matthew R Brier
- Washington University School of Medicine, Department of Neurology, Saint Louis, MO
| | | | - Gregory S Day
- Mayo Clinic Florida, Department of Neurology; Jacksonville, FL
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6
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Popova E, Mathai A, Kannoth S, Nair P, Sasikumar S, Gopinath S, Nambiar V, Anandakuttan A, Umesh SU, Leelamaniamma JV. Cerebrospinal fluid indices as predictors of treatment response in autoimmune encephalitis. Mult Scler Relat Disord 2023; 79:104996. [PMID: 37703639 DOI: 10.1016/j.msard.2023.104996] [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: 07/28/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) indices reflecting intrathecal antibody production and blood-brain barrier impairment are not routinely assessed in patients with autoimmune encephalitis (AE). We aimed to study CSF indices and their association with the prognosis of AE. METHODS This retrospective cohort study conducted at Amrita Institute of Medical Sciences (AIMS), Kochi, India, included 60 patients aged more than 18 years with definite/probable/possible AE admitted to the Department of Neurology from August 2016 to November 2021. We introduced a classification of treatment response based on modified Rankin Scale change over time and treatment modalities. RESULTS In our cohort of 60 patients (six [10%] seropositive cases), a good rapid treatment response was associated with CSF white blood cell count of more than 4 cells/mm3 (OR, 4.57; 95% CI 1.31-15.96; P = .02) and positive immunoglobulin G (IgG) Local Synthesis (OR, 7.27; 95% CI 1.56-33.86; P = .01). Albumin Index had association with a poor Glasgow Coma Scale score at the nadir of the disease (OR, 1.17; 95% CI 1.01-1.34; P = .04). Similar results were yielded in the seronegative cohort. IgG Local Synthesis appeared to be a strong predictor for good rapid treatment response in both univariate and multivariate (adjusted OR, 28.71; 95% CI 2.12-389.22; P= .01) analysis. Time to immunotherapy was reversely correlated with good response overall (in the cohort with outliers removed [N = 49]: unadjusted OR 0.97, 95% CI 0.95-0.99; P= .01; adjusted OR 0.97; 95% CI 0.95-0.99; P= .008). CONCLUSION CSF indices reflecting intrathecal antibody production and blood-brain barrier impairment appear to be promising predictors of disease severity and therapeutic response in patients with autoimmune encephalitis.
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Affiliation(s)
- Ekaterina Popova
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Annamma Mathai
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India; Neuroimmunology Laboratory, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Sudheeran Kannoth
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India; Neuroimmunology Laboratory, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India.
| | - Pranav Nair
- Department of Radiation Oncology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Sruthi Sasikumar
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Siby Gopinath
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Anandkumar Anandakuttan
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Saraf Udit Umesh
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
| | - Jyothi Vikramanpillai Leelamaniamma
- Department of Neurology, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India; Neuroimmunology Laboratory, Amrita Institute of Medical Sciences (AIMS), Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara PO, Kochi, Kerala 682041, India
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7
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Gillon S, Chan M, Chen J, Guterman EL, Wu X, Glastonbury CM, Li Y. MR Imaging Findings in a Large Population of Autoimmune Encephalitis. AJNR Am J Neuroradiol 2023:ajnr.A7907. [PMID: 37385678 PMCID: PMC10337613 DOI: 10.3174/ajnr.a7907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Autoimmune encephalitis is a rare condition in which autoantibodies attack neuronal tissue, causing neuropsychiatric disturbances. This study sought to evaluate MR imaging findings associated with subtypes and categories of autoimmune encephalitis. MATERIALS AND METHODS Cases of autoimmune encephalitis with specific autoantibodies were identified from the medical record (2009-2019). Cases were excluded if no MR imaging of the brain was available, antibodies were associated with demyelinating disease, or >1 concurrent antibody was present. Demographics, CSF profile, antibody subtype and group (group 1 intracellular antigen or group 2 extracellular antigen), and MR imaging features at symptom onset were reviewed. Imaging and clinical features were compared across antibody groups using χ2 and Wilcoxon rank-sum tests. RESULTS Eighty-five cases of autoimmune encephalitis constituting 16 distinct antibodies were reviewed. The most common antibodies were anti-N-methyl-D-aspartate (n = 41), anti-glutamic acid decarboxylase (n = 7), and anti-voltage-gated potassium channel (n = 6). Eighteen of 85 (21%) were group 1; and 67/85 (79%) were group 2. The median time between MR imaging and antibody diagnosis was 14 days (interquartile range, 4-26 days). MR imaging had normal findings in 33/85 (39%), and 20/33 (61%) patients with normal MRIs had anti-N-methyl-D-aspartate receptor antibodies. Signal abnormality was most common in the limbic system (28/85, 33%); 1/68 (1.5%) had susceptibility artifacts. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2. CONCLUSIONS Sixty-one percent of patients with autoimmune encephalitis had abnormal brain MR imaging findings at symptom onset, most commonly involving the limbic system. Susceptibility artifact is rare and makes autoimmune encephalitis less likely as a diagnosis. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2.
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Affiliation(s)
- S Gillon
- From the School of Medicine (S.G., J.C.)
| | - M Chan
- Department of Radiology (M.C.), University of Toronto, Toronto, Ontario, Canada
| | - J Chen
- From the School of Medicine (S.G., J.C.)
| | | | - X Wu
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - C M Glastonbury
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - Y Li
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
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8
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Marsili L, Marcucci S, LaPorta J, Chirra M, Espay AJ, Colosimo C. Paraneoplastic Neurological Syndromes of the Central Nervous System: Pathophysiology, Diagnosis, and Treatment. Biomedicines 2023; 11:biomedicines11051406. [PMID: 37239077 DOI: 10.3390/biomedicines11051406] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Paraneoplastic neurological syndromes (PNS) include any symptomatic and non-metastatic neurological manifestations associated with a neoplasm. PNS associated with antibodies against intracellular antigens, known as "high-risk" antibodies, show frequent association with underlying cancer. PNS associated with antibodies against neural surface antigens, known as "intermediate- or low-risk" antibodies, are less frequently associated with cancer. In this narrative review, we will focus on PNS of the central nervous system (CNS). Clinicians should have a high index of suspicion with acute/subacute encephalopathies to achieve a prompt diagnosis and treatment. PNS of the CNS exhibit a range of overlapping "high-risk" clinical syndromes, including but not limited to latent and overt rapidly progressive cerebellar syndrome, opsoclonus-myoclonus-ataxia syndrome, paraneoplastic (and limbic) encephalitis/encephalomyelitis, and stiff-person spectrum disorders. Some of these phenotypes may also arise from recent anti-cancer treatments, namely immune-checkpoint inhibitors and CAR T-cell therapies, as a consequence of boosting of the immune system against cancer cells. Here, we highlight the clinical features of PNS of the CNS, their associated tumors and antibodies, and the diagnostic and therapeutic strategies. The potential and the advance of this review consists on a broad description on how the field of PNS of the CNS is constantly expanding with newly discovered antibodies and syndromes. Standardized diagnostic criteria and disease biomarkers are fundamental to quickly recognize PNS to allow prompt treatment initiation, thus improving the long-term outcome of these conditions.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Samuel Marcucci
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Joseph LaPorta
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Martina Chirra
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, 05100 Terni, Italy
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9
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Jeppesen R, Nilsson AC, Sørensen NV, Orlovska-Waast S, Christensen RHB, Benros ME. Antineuronal antibodies in cerebrospinal fluid and serum of 104 patients with psychotic disorders compared to 104 individually matched healthy controls. Schizophr Res 2023; 252:39-45. [PMID: 36621326 DOI: 10.1016/j.schres.2022.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 11/08/2022] [Accepted: 12/26/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Antineuronal antibodies can cause psychotic symptoms, particularly NMDAR antibodies; however, studies on the prevalence of antineuronal antibodies in cerebrospinal fluid (CSF) and serum of patients with psychotic disorders compared to matched healthy controls are sparse. METHODS We included 104 patients with a first-time diagnosis of a psychotic disorder within one year prior to inclusion (50 % outpatients) and 104 individually matched healthy controls, all without any known immunological conditions. CSF and serum were tested for IgG antibodies (Abs) against NMDAR NR1-subunit, GAD65, LGI1, CASPR2, AMPAR1, AMPAR2 and GABAb-receptor B1/B2 using commercial fixed cell-based assays (CBAs) (Euroimmun). Positive samples were retested with CBA twice, and tested with tissue-based assays (TBA). Primary outcomes were the presence of any of the seven anti-neuronal antibodies in CSF or serum. Secondarily, we analyzed the prevalence of each autoantibody. RESULTS No antineuronal IgG antibodies were consistently found in any CSF sample and NMDAR-antibodies were not consistently present in any of the 208 participants, neither in CSF nor serum. CASPR2-Abs were consistently found in the serum of one patient and one control, and one healthy control, without diabetes, was seropositive for GAD65-Abs. CASPR2 borderline seropositivity was additionally found in one patient and two controls. All samples positive on CBA were negative on TBA. CONCLUSIONS We found no significant differences between patients and controls. Antineuronal IgG antibodies are very rare when screening a broad group of individuals with recent-onset psychotic disorders without other indications of autoimmune encephalitis. Thus, much larger studies are needed to conclude on potential contrasts in prevalence compared to healthy controls.
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Affiliation(s)
- Rose Jeppesen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Centre, Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anna Christine Nilsson
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Nina Vindegaard Sørensen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Centre, Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sonja Orlovska-Waast
- Copenhagen Research Center for Mental Health - CORE, Mental Health Centre, Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rune Haubo Bojesen Christensen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Centre, Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael Eriksen Benros
- Copenhagen Research Center for Mental Health - CORE, Mental Health Centre, Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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10
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Unexplained Progressive Neurological Deficits after Corpus Callosotomy May Be Caused by Autoimmune Encephalitis: A Case of Suspected Postoperative Anti-NMDAR Encephalitis. Brain Sci 2023; 13:brainsci13010135. [PMID: 36672116 PMCID: PMC9856623 DOI: 10.3390/brainsci13010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
The main causes of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are ovarian teratoma and herpes simplex virus (HSV) encephalitis. We present a rare case of suspected anti-NMDAR encephalitis caused by corpus callosotomy (CC). An 18-year-old woman with Lennox-Gastaut syndrome underwent CC. Although left hemiplegic due to cerebral hemorrhage and impaired consciousness due to cerebral venous sinus thrombosis (CVST) appeared postoperatively, anticoagulant therapy quickly improved CVST and impaired consciousness. However, various unexplained symptoms such as insomnia, hallucination, impulsivity, impaired consciousness, and a new type of drug-resistant cluster seizures gradually developed over a 2-month period. Magnetic resonance imaging revealed the gradual extension of a hyperintense area from the right frontal lobe on fluid-attenuated inversion recovery images. Intravenous methylprednisolone pulse was initiated from postoperative day (POD) 74, followed by intravenous immunoglobulin (IVIg) therapy, although white blood cell counts were normal in all three cerebrospinal fluid (CSF) examinations. After IVIg therapy, the above unexplained symptoms promptly improved. On POD 103, antibodies against NMDAR were revealed in both the serum and CSF collected before these immunotherapies. The patient was transferred to a rehabilitation hospital due to residual left hemiplegia. Psychiatric symptoms and a new onset of drug-resistant seizures may be suggestive of postoperative anti-NMDAR encephalitis, even if CSF findings are mild.
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11
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Flanagan EP, Geschwind MD, Lopez-Chiriboga AS, Blackburn KM, Turaga S, Binks S, Zitser J, Gelfand JM, Day GS, Dunham SR, Rodenbeck SJ, Clardy SL, Solomon AJ, Pittock SJ, McKeon A, Dubey D, Zekeridou A, Toledano M, Turner LE, Vernino S, Irani SR. Autoimmune Encephalitis Misdiagnosis in Adults. JAMA Neurol 2023; 80:30-39. [PMID: 36441519 PMCID: PMC9706400 DOI: 10.1001/jamaneurol.2022.4251] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022]
Abstract
Importance Autoimmune encephalitis misdiagnosis can lead to harm. Objective To determine the diseases misdiagnosed as autoimmune encephalitis and potential reasons for misdiagnosis. Design, Setting, and Participants This retrospective multicenter study took place from January 1, 2014, to December 31, 2020, at autoimmune encephalitis subspecialty outpatient clinics including Mayo Clinic (n = 44), University of Oxford (n = 18), University of Texas Southwestern (n = 18), University of California, San Francisco (n = 17), University of Washington in St Louis (n = 6), and University of Utah (n = 4). Inclusion criteria were adults (age ≥18 years) with a prior autoimmune encephalitis diagnosis at a participating center or other medical facility and a subsequent alternative diagnosis at a participating center. A total of 393 patients were referred with an autoimmune encephalitis diagnosis, and of those, 286 patients with true autoimmune encephalitis were excluded. Main Outcomes and Measures Data were collected on clinical features, investigations, fulfillment of autoimmune encephalitis criteria, alternative diagnoses, potential contributors to misdiagnosis, and immunotherapy adverse reactions. Results A total of 107 patients were misdiagnosed with autoimmune encephalitis, and 77 (72%) did not fulfill diagnostic criteria for autoimmune encephalitis. The median (IQR) age was 48 (35.5-60.5) years and 65 (61%) were female. Correct diagnoses included functional neurologic disorder (27 [25%]), neurodegenerative disease (22 [20.5%]), primary psychiatric disease (19 [18%]), cognitive deficits from comorbidities (11 [10%]), cerebral neoplasm (10 [9.5%]), and other (18 [17%]). Onset was acute/subacute in 56 (52%) or insidious (>3 months) in 51 (48%). Magnetic resonance imaging of the brain was suggestive of encephalitis in 19 of 104 patients (18%) and cerebrospinal fluid (CSF) pleocytosis occurred in 16 of 84 patients (19%). Thyroid peroxidase antibodies were elevated in 24 of 62 patients (39%). Positive neural autoantibodies were more frequent in serum than CSF (48 of 105 [46%] vs 7 of 91 [8%]) and included 1 or more of GAD65 (n = 14), voltage-gated potassium channel complex (LGI1 and CASPR2 negative) (n = 10), N-methyl-d-aspartate receptor by cell-based assay only (n = 10; 6 negative in CSF), and other (n = 18). Adverse reactions from immunotherapies occurred in 17 of 84 patients (20%). Potential contributors to misdiagnosis included overinterpretation of positive serum antibodies (53 [50%]), misinterpretation of functional/psychiatric, or nonspecific cognitive dysfunction as encephalopathy (41 [38%]). Conclusions and Relevance When evaluating for autoimmune encephalitis, a broad differential diagnosis should be considered and misdiagnosis occurs in many settings including at specialized centers. In this study, red flags suggesting alternative diagnoses included an insidious onset, positive nonspecific serum antibody, and failure to fulfill autoimmune encephalitis diagnostic criteria. Autoimmune encephalitis misdiagnosis leads to morbidity from unnecessary immunotherapies and delayed treatment of the correct diagnosis.
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Affiliation(s)
- Eoin P. Flanagan
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael D. Geschwind
- Department of Neurology, University of California, San Francisco (UCSF), San Francisco
| | | | - Kyle M. Blackburn
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Sanchit Turaga
- Autoimmune Neurology Group, West Wing, Level 3, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sophie Binks
- Autoimmune Neurology Group, West Wing, Level 3, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Jennifer Zitser
- Department of Neurology, University of California, San Francisco (UCSF), San Francisco
- Movement Disorders Unit, Department of Neurology, Tel Aviv Sourazky Medical Center, Affiliate of Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeffrey M. Gelfand
- Department of Neurology, University of California, San Francisco (UCSF), San Francisco
| | - Gregory S. Day
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
- Washington University in St Louis, St Louis, Missouri
| | | | | | | | | | - Sean J. Pittock
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Andrew McKeon
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Divyanshu Dubey
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Anastasia Zekeridou
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michel Toledano
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Lindsey E. Turner
- Graduate School of Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Steven Vernino
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Sarosh R. Irani
- Autoimmune Neurology Group, West Wing, Level 3, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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12
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Vale S. Reader Response: Neurofilament Light Chain Levels in Anti-NMDAR Encephalitis and Primary Psychiatric Psychosis. Neurology 2022; 99:491. [PMID: 36096677 DOI: 10.1212/wnl.0000000000201180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Thomas R, Hernandez MJ, Thomas R. Psychosis After Infection With SARS-CoV-2 in an Adolescent: A Case Report. J Am Acad Child Adolesc Psychiatry 2022; 61:844-847. [PMID: 35278631 PMCID: PMC8904030 DOI: 10.1016/j.jaac.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/19/2022] [Accepted: 03/02/2022] [Indexed: 10/25/2022]
Abstract
As many as one-third of patients who have coronavirus disease 2019 (COVID-19) develop long-term neuropsychiatric symptoms, such as anxiety, depression, brain fog, psychosis, seizures, and suicidal behavior.1 Several case reports have demonstrated the association between psychotic symptoms following infection with COVID-19 in adults.1,2 In a first episode of psychosis, clinical findings on history, examination, and diagnostic studies may suggest that the psychotic symptoms are due to medical illness, which may be reversible. The presentation can include acute onset, predominance of visual or tactile hallucinations, and association with other neurological symptoms.3.
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Affiliation(s)
- Reena Thomas
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
| | | | - Roy Thomas
- Northwestern McGaw Family Medicine Residency at Delnor Hospital, Geneva, Illinois
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14
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Santoro JD, Partridge R, Tanna R, Pagarkar D, Khoshnood M, Rehmani M, Kammeyer RM, Gombolay GY, Fisher K, Conravey A, El-Dahr J, Christy AL, Patel L, Manning MA, Van Mater H, Rafii MS, Quinn EA. Evidence of neuroinflammation and immunotherapy responsiveness in individuals with down syndrome regression disorder. J Neurodev Disord 2022; 14:35. [PMID: 35659536 PMCID: PMC9164321 DOI: 10.1186/s11689-022-09446-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/26/2022] [Indexed: 11/29/2022] Open
Abstract
Background Down syndrome regression disorder is a symptom cluster consisting of neuropsychiatric regression without cause. This study evaluated the incidence of neurodiagnostic abnormalities in individuals with Down syndrome regression disorder and determined if abnormalities are indicative of responses to therapeutic intervention. Methods A retrospective, multi-center, case-control study was performed. Patients were required to have subacute onset and the presence of four of five symptom groups present (cognitive decline, expressive language, sleep derangement, loss of ability to perform activities of daily living, and/or a new movement disorder) and no other explanation for symptoms. Results Individuals with Down syndrome regression disorder were comparable to a cohort of individuals with only Down syndrome although had higher rates of autoimmune disease (p = 0.02, 95%CI 1.04–1.75). Neurodiagnostic abnormalities were found on EEG (n = 19, 26%), neuroimaging (n = 16, 22%), and CSF (n = 9, 17%). Pleocytosis was appreciated in five cases, elevated total protein in nine, elevated IgG index in seven, and oligoclonal bands in two. Testing within 2 years of symptom onset was more likely to have neurodiagnostic abnormalities (p = 0.01, 95%CI 1.64–37.06). In individuals with neurodiagnostic abnormalities, immunotherapy was nearly four times more likely to have a therapeutic effect than in those without neurodiagnostic abnormalities (OR 4.11, 95%CI 1.88–9.02). In those with normal neurodiagnostic studies (n = 43), IVIg was effective in 14 of 17 (82%) patients as well although other immunotherapies were uniformly ineffective. Conclusions This study reports the novel presence of neurodiagnostic testing abnormalities in individuals with Down syndrome regression disorder, providing credence to this symptom cluster potentially being of neurologic and/or neuroimmunologic etiology. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-022-09446-w.
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Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS82, Los Angeles, CA, 90027, USA. .,Department of Neurology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.
| | | | - Runi Tanna
- Keck School of Medicine at the University of Southern California, Los Angeles, USA
| | - Dania Pagarkar
- Keck School of Medicine at the University of Southern California, Los Angeles, USA
| | - Mellad Khoshnood
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS82, Los Angeles, CA, 90027, USA
| | - Mustafa Rehmani
- Department of Psychiatry, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Ryan M Kammeyer
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Emory University School of Medicine, Atlanta, GA, USA
| | - Kristen Fisher
- Division of Neurology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Jane El-Dahr
- Section of Pediatric Allergy, Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Lina Patel
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Melanie A Manning
- Division of Medical Genetics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Heather Van Mater
- Division of Rheumatology, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Michael S Rafii
- Department of Neurology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.,Alzheimer's Therapeutic Research Institute (ATRI), Keck School of Medicine at the University of Southern California, San Diego, CA, USA
| | - Eileen A Quinn
- Department of Pediatrics, University of Toledo College of Medicine and Life Science, Toledo, OH, USA
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15
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Abstract
PURPOSE OF REVIEW This article presents a practical approach to the evaluation of patients with rapidly progressive dementia. RECENT FINDINGS The approach presented in this article builds upon the standard dementia evaluation, leveraging widely available tests and emergent specific markers of disease to narrow the differential diagnosis and determine the cause(s) of rapid progressive decline. The discovery of treatment-responsive causes of rapidly progressive dementia underscores the need to determine the cause early in the symptomatic course when treatments are most likely to halt or reverse cognitive decline. SUMMARY A pragmatic and organized approach to patients with rapidly progressive dementia is essential to mitigate diagnostic and therapeutic challenges and optimize patient outcomes.
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16
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Schindler SE. Fluid Biomarkers in Dementia Diagnosis. Continuum (Minneap Minn) 2022; 28:822-833. [PMID: 35678404 DOI: 10.1212/con.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article discusses how fluid biomarkers can augment the routine dementia evaluation and improve diagnostic accuracy. The tests that are currently available and the indications for their use are described. Further, tests that are under development and likely to be used in the future are identified. RECENT FINDINGS Technical improvements in assay sensitivity and precision have led to the rapid development of blood-based biomarkers for Alzheimer disease (AD) over the past several years. Studies have found that the ratio of amyloid-β (Aβ) peptides (Aβ42/Aβ40) and concentrations of phosphorylated tau isoforms in plasma can identify individuals with AD brain pathology. Blood-based tests may enable much broader use of AD biomarkers in the evaluation of patients with cognitive impairment. SUMMARY Even after a detailed history, examination, routine laboratory testing, and brain imaging, the cause of dementia sometimes remains unclear. CSF and blood-based biomarkers can evaluate for a range of neurologic disorders that are associated with dementia, including AD. Integrating data from fluid biomarker tests and the routine dementia evaluation may improve the accuracy of dementia diagnosis.
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Shir D, Day GS. Deciphering the contributions of neuroinflammation to neurodegeneration: lessons from antibody-mediated encephalitis and coronavirus disease 2019. Curr Opin Neurol 2022; 35:212-219. [PMID: 35102125 PMCID: PMC8896289 DOI: 10.1097/wco.0000000000001033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW Does neuroinflammation promote neurodegeneration? Does neurodegeneration promote neuroinflammation? Or, is the answer to both questions, yes? These questions have proven challenging to answer in patients with typical age-related neurodegenerative diseases in whom the onset of neuroinflammation and neurodegeneration are largely unknown. Patients recovering from diseases associated with abrupt-onset neuroinflammation, including rare forms of antibody-mediated encephalitis (AME) and common complications of novel coronavirus disease 2019 (COVID-19), provide a unique opportunity to untangle the relationship between neuroinflammation and neurodegeneration. This review explores the lessons learned from patients with AME and COVID-19. RECENT FINDINGS Persistent cognitive impairment is increasingly recognized in patients recovering from AME or COVID-19, yet the drivers of impairment remain largely unknown. Clinical observations, neuroimaging and biofluid biomarkers, and pathological studies imply a link between the severity of acute neuroinflammation, subsequent neurodegeneration, and disease-associated morbidity. SUMMARY Data from patients with AME and COVID-19 inform key hypotheses that may be evaluated through future studies incorporating longitudinal biomarkers of neuroinflammation and neurodegeneration in larger numbers of recovering patients. The results of these studies may inform the contributors to cognitive impairment in patients with AME and COVID-19, with potential diagnostic and therapeutic applications in patients with age-related neurodegenerative diseases.
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Affiliation(s)
- Dror Shir
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Gregory S. Day
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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18
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Hébert J, Muccilli A, Wennberg RA, Tang-Wai DF. Autoimmune Encephalitis and Autoantibodies: A Review of Clinical Implications. J Appl Lab Med 2022; 7:81-98. [PMID: 34996085 DOI: 10.1093/jalm/jfab102] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a common cause of encephalitis. We review the most recent evidence on this neuroimmune condition and autoantibody testing currently available. CONTENT Clinical criteria, neuroimaging and electroencephalography can facilitate the diagnosis of AE prior to obtaining autoantibody testing results, and lead to a diagnosis of AE even in the absence of a recognized antibody. Early treatment of AE has been found to correlate with improved long-term functional and cognitive outcomes. We suggest a clinical approach to diagnosis based on the predominant area of nervous system involvement and the results of ancillary testing that are widely available. We also propose a 2-tiered approach to the acute management of probable or definite AE. We, finally, provide guidance on the long-term management of AE-a challenging and understudied area. SUMMARY Much work remains to be done to improve the care of patients with AE. As understanding of the pathophysiology and predisposing factors underlying this condition steadily increases, a more evidence-based, targeted approach to the treatment of AE is still desired. Nonetheless, looking at the progress made over the past 2 decades, since the discovery of the first autoantibodies associated with AE, one cannot help but feel optimistic about the road ahead.
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Affiliation(s)
- Julien Hébert
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Alexandra Muccilli
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Multiple Sclerosis Clinic, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard A Wennberg
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Epilepsy Clinic and Neurophysiology Lab, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, Division of Neurology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Neurology, Memory Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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19
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Usefulness of brain FDG PET/CT imaging in pediatric patients with suspected autoimmune encephalitis from a prospective study. Eur J Nucl Med Mol Imaging 2021; 49:1918-1929. [PMID: 34939173 PMCID: PMC9016000 DOI: 10.1007/s00259-021-05649-w] [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: 09/15/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022]
Abstract
Purpose Early diagnosis and treatment are of paramount importance for pediatric patients with autoimmune encephalitis (AE). The aim is to evaluate the usefulness of FDG PET/CT in pediatric patients with suspected AE from a prospective study. Methods The prospective study was conducted over a period of 23.5 months from May 14, 2019, to April 30, 2021. All patients (< 18-year-old) were hospitalized at the department of pediatric neurology and met the criteria of clinical suspected AE. The children underwent the tests of blood samplings, CSF, EEG, MRI, and 18F-FDG PET/CT. The criteria for FDG PET/CT diagnosis of AE were large lobar hypometabolism with or without focal hypermetabolism found on PET/CT. The clinical final diagnosis of AE includes seropositive and seronegative AE based on the diagnostic criteria. Results One hundred four pediatric inpatients (57 boys, 47 girls) were included, of which 58 children were diagnosed with AE (seropositive, 16; seronegative, 42), 45 children were diagnosed with non-AE, and one boy remained indeterminate diagnosis. Large lobar hypometabolism was found in 61 children, of which 54 (88.5%) children were finally diagnosed with AE. The sensitivity, specificity, and accuracy of FDG PET/CT for diagnosis of AE were 93.1%, 84.4%, and 89.3%, respectively, with a positive predictive value of 88.5% and a negative predictive value of 90.5%. The most common involved with hypometabolism was the parietal lobe, followed by occipital and frontal lobes, finally the temporal lobe on PET/CT in children with AE. Conclusion Brain FDG PET/CT imaging has high specificity, sensitivity, and accuracy for diagnosis of AE in clinical suspected AE children. Trial registration. Clinical Trials.gov. NCT02969213. Registered 17 October 2016.
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20
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Abstract
Meningitis and encephalitis are inflammatory syndromes of the meninges and brain parenchyma, respectively, and may be identified either by finding definitive evidence of inflammation on tissue pathology or by cerebrocpinal fluid (CSF) analysis showing pleocytosis or intrathecal antibody synthesis. Clinicians evaluating undifferentiated meningitis or encephalitis should simultaneously consider autoimmune, infectious, and neoplastic causes, using patient risk factors, clinical syndrome, and diagnostic results including CSF and MRI findings to narrow the differential diagnosis. If an autoimmune cause is favored, an important early diagnostic question is whether a specific neural autoantibody is likely to be identified.
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Affiliation(s)
- Megan B Richie
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
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21
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Decrease in the cortex/striatum metabolic ratio on [ 18F]-FDG PET: a biomarker of autoimmune encephalitis. Eur J Nucl Med Mol Imaging 2021; 49:921-931. [PMID: 34462791 DOI: 10.1007/s00259-021-05507-9] [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: 03/15/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this [18F]-FDG PET study was to determine the diagnostic value of the cortex/striatum metabolic ratio in a large cohort of patients suffering from autoimmune encephalitis (AE) and to search for correlations with the course of the disease. METHODS We retrospectively collected clinical and paraclinical data of patients with AE, including brain 18F-FDG PET/CT. Whole-brain statistical analysis was performed using SPM8 software after activity parametrization to the striatum in comparison to healthy subjects. The discriminative performance of this metabolic ratio was evaluated in patients with AE using receiver operating characteristic curves against 44 healthy subjects and a control group of 688 patients with MCI. Relationship between cortex/striatum metabolic ratios and clinical/paraclinical data was assessed using univariate and multivariate analysis in patients with AE. RESULTS Fifty-six patients with AE were included. In comparison to healthy subjects, voxel-based statistical analysis identified one large cluster (p-cluster < 0.05, FWE corrected) of widespread decreased cortex/striatum ratio in patients with AE. The mean metabolic ratio was significantly lower for AE patients (1.16 ± 0.13) than that for healthy subjects (1.39 ± 0.08; p < 0.001) and than that for MCI patients (1.32 ± 0.11; p < 0.001). A ratio threshold of 1.23 allowed to detect AE patients with a sensitivity of 71% and a specificity of 82% against MCI patients, and 98% against healthy subjects. A lower cortex/striatum metabolic ratio had a trend towards shorter delay before 18F-FDG PET/CT (p = 0.07) in multivariate analysis. CONCLUSION The decrease in the cortex/striatal metabolic ratio has a good early diagnostic performance for the differentiation of AE patients from controls.
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22
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Bastiaansen AEM, van Steenhoven RW, de Bruijn MAAM, Crijnen YS, van Sonderen A, van Coevorden-Hameete MH, Nühn MM, Verbeek MM, Schreurs MWJ, Sillevis Smitt PAE, de Vries JM, Jan de Jong F, Titulaer MJ. Autoimmune Encephalitis Resembling Dementia Syndromes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1039. [PMID: 34341093 PMCID: PMC8362342 DOI: 10.1212/nxi.0000000000001039] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
Objective As autoimmune encephalitis (AIE) can resemble neurodegenerative dementia
syndromes, and patients do not always present as encephalitis, this study
evaluates how frequently AIE mimics dementia and provides red flags for AIE
in middle-aged and older patients. Methods In this nationwide observational cohort study, patients with
anti–leucine-rich glioma-inactivated 1 (LGI1), anti–NMDA
receptor (NMDAR), anti–gamma-aminobutyric acid B receptor
(GABABR), or anti–contactin-associated protein-like 2
(CASPR2) encephalitis were included. They had to meet 3 additional criteria:
age ≥45 years, fulfillment of dementia criteria, and no prominent
seizures early in the disease course (≤4 weeks). Results Two-hundred ninety patients had AIE, of whom 175 were 45 years or older.
Sixty-seven patients (38%) fulfilled criteria for dementia without prominent
seizures early in the disease course. Of them, 42 had anti-LGI1 (48%), 13
anti-NMDAR (52%), 8 anti-GABABR (22%), and 4 anti-CASPR2 (15%)
encephalitis. Rapidly progressive cognitive deterioration was seen in 48
patients (76%), whereas a neurodegenerative dementia syndrome was suspected
in half (n = 33). In 17 patients (27%; 16/17 anti-LGI1), subtle
seizures had been overlooked. Sixteen patients (25%) had neither
inflammatory changes on brain MRI nor CSF pleocytosis. At least 1 CSF
biomarker, often requested when dementia was suspected, was abnormal in 27
of 44 tested patients (61%), whereas 8 had positive 14-3-3 results (19%).
Most patients (84%) improved after immunotherapy. Conclusions Red flags for AIE in patients with suspected dementia are: (1) rapidly
progressive cognitive decline, (2) subtle seizures, and (3) abnormalities in
ancillary testing atypical for neurodegeneration. Physicians should be aware
that inflammatory changes are not always present in AIE, and that biomarkers
often requested when dementia was suspected (including 14-3-3) can show
abnormal results. Diagnosis is essential as most patients profit from
immunotherapy.
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Affiliation(s)
- Anna E M Bastiaansen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robin W van Steenhoven
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marienke A A M de Bruijn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvette S Crijnen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Agnes van Sonderen
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marleen H van Coevorden-Hameete
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke M Nühn
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marcel M Verbeek
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank Jan de Jong
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (A.E.M.B., R.W.v.S., Y.S.C., M.H.v.C.-H., P.A.E.S.S., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam; Department of Neurology, VU University Medical Center, Amsterdam (R.W.v.S.); Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, Tilburg; Department of Neurology (A.v.S.), Haaglanden Medical Center, The Hague; Honours Student Bachelor Biomedical Sciences (M.M.N.), University Utrecht; Department of Neurology and Laboratory Medicine (M.M.V.), Donders Institute for Brain Cognition and Behavior, Radboud University Medical Center, Nijmegen; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam; and Alzheimer Center Erasmus MC (F.J.d.J.), Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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23
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Mueller C, Langenbruch LM, Rau JMH, Brix T, Strippel C, Dik A, Golombeck KS, Moenig C, Raeuber SJ, Kovac S, Wiendl H, Meuth SG, Bölte J, Johnen A, Melzer N. Determinants of cognition in autoimmune limbic encephalitis-A retrospective cohort study. Hippocampus 2021; 31:1092-1103. [PMID: 34270832 DOI: 10.1002/hipo.23375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/24/2022]
Abstract
Autoimmune limbic encephalitis (ALE) is the most common type of autoimmune encephalitis (AIE). Subacute memory disturbance, temporal lobe seizures, and psychiatric symptoms are clinical hallmarks of the disease. However, little is known on the factors contributing to cognitive functioning in ALE. Hence, we here investigate major determinants of cognitive functioning in ALE. In a retrospective analysis of 102 patients with ALE, we first compared verbal learning capacity, nonverbal learning capacity, and attentional and executive functioning by absence or presence of different types of neural autoantibodies (AABs). Subsequently we established three linear regression models including 63, 38, and 61 patients, respectively to investigate how cognitive functioning in these domains may depend on common markers of ALE such as intrathecal inflammation, blood-cerebrospinal fluid (CSF)-barrier function, mesiotemporal epileptiform discharges and slowing, determined by electroencephalography (EEG) and structural mesiotemporal changes, measured with magnetic resonance imaging (MRI). We also accounted for possible effects of cancer- and immunotherapy and other centrally effective medication. There was no effect of AAB status on cognitive functioning. Although the regression models could not predict verbal and nonverbal learning capacity, structural mesiotemporal neural network alterations on T2-/fluid attenuated inversion recovery (FLAIR)-signal-weighted MRI and mesiotemporal epileptiform discharges or slowing on EEG exerted a significant impact on memory functions. In contrast, the regression model significantly predicted attentional and executive functioning with CSF white blood cell count and centrally effective medication being significant determinants. In this cohort, cognitive functioning in ALE does not depend on the AAB status. Common markers of ALE cannot predict memory functioning that only partially depends on structural and functional alterations of mesiotemporal neural networks. Common markers of ALE significantly predict attentional and executive functioning that is significantly related to centrally effective medication and CSF white blood cell count, which may point toward inflammation affecting brain regions beyond the limbic system.
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Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Lisa M Langenbruch
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Johanna M H Rau
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Tobias Brix
- Institute of Medical Informatics, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Andre Dik
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Kristin S Golombeck
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Constanze Moenig
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Saskia J Raeuber
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
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24
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Abbatemarco JR, Rodenbeck SJ, Day GS, Titulaer MJ, Yeshokumar AK, Clardy SL. Autoimmune Neurology: The Need for Comprehensive Care. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1033. [PMID: 34131068 PMCID: PMC8207636 DOI: 10.1212/nxi.0000000000001033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/03/2021] [Indexed: 12/23/2022]
Abstract
Autoimmune neurology is a rapidly developing specialty driven by an increasing recognition of autoimmunity as the cause for a broad set of neurologic disorders and ongoing discovery of new neural autoantibodies associated with recognizable clinical syndromes. The diversity of clinical presentations, unique pathophysiology, and the complexity of available treatments requires a dedicated multidisciplinary team to diagnose and manage patients. In this article, we focus on antibody-associated autoimmune encephalitis (AE) to illustrate broader themes applicable to the specialty. We discuss common diagnostic challenges including the utilization of clinical assessment tools along with the determination of the prognostic significance of certain autoantibodies, with a focus on implications for long-term management. A growing body of literature demonstrates the long-term cognitive, behavioral, and physical sequelae of AE. Dedicated resources are needed to effectively manage these patients. These resources may be best provided by experienced neurology clinics in partnership with other neurologic subspecialists, as well as psychiatrists, neuropsychologists, and physical medicine and rehabilitation providers.
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Affiliation(s)
- Justin R Abbatemarco
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Stefanie J Rodenbeck
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Gregory S Day
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Maarten J Titulaer
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Anusha K Yeshokumar
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT
| | - Stacey L Clardy
- From the Department of Neurology (J.R.A., S.J.R., S.L.C.), University of Utah, Salt Lake City; Department of Neurology (G.S.D.), Mayo Clinic in Florida, Jacksonville; Department of Neurology (M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; and George E. Wahlen Veterans Affairs Medical Center (S.L.C.), Salt Lake City, UT.
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25
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Zrzavy T, Höftberger R, Wimmer I, Berger T, Rommer P, Macher S. Longitudinal CSF Findings in Autoimmune Encephalitis-A Monocentric Cohort Study. Front Immunol 2021; 12:646940. [PMID: 33828556 PMCID: PMC8019787 DOI: 10.3389/fimmu.2021.646940] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/24/2021] [Indexed: 11/13/2022] Open
Abstract
Autoimmune encephalitis (AIE) poses a diagnostic challenge due to its heterogeneous clinical presentation, which overlaps with various neurological and psychiatric diseases. During the diagnostic work-up, cerebrospinal fluid (CSF) is routinely obtained, allowing for differential diagnostics as well as for the determination of antibody subclasses and specificities. In this monocentric cohort study, we describe initial and serial CSF findings of 33 patients diagnosed with antibody-associated AIE (LGI1 (n=8), NMDA (n=7), CASPR2 (n=3), IgLON5 (n=3), AMPAR (n=1), GAD65/67 (n=4), Yo (n=3), Ma-1/2 (n=2), CV2 (n=2)). Routine CSF parameters of 12.1% of AIE patients were in normal ranges, while 60.6% showed elevated protein levels and 45.4% had intrathecal oligoclonal bands (OCBs). Repeated CSF analyses showed a trend towards normalization of initial pathological CSF findings, while relapses were more likely to be associated with increased cell counts and total protein levels. OCB status conversion in anti-NMDARE patients coincided with clinical improvement. In summary, we show that in routine CSF analysis at diagnosis, a considerable number of patients with AIE did not exhibit alteration in the CSF and therefore, diagnosis may be delayed if antibody testing is not performed. Moreover, OCB status in anti-NMDAR AIE patients could represent a potential prognostic biomarker, however further studies are necessary to validate these exploratory findings.
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Affiliation(s)
- Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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26
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Hayden Z, Bóné B, Orsi G, Szots M, Nagy F, Csépány T, Mezei Z, Rajda C, Simon D, Najbauer J, Illes Z, Berki T. Clinical Characteristics and Outcome of Neuronal Surface Antibody-Mediated Autoimmune Encephalitis Patients in a National Cohort. Front Neurol 2021; 12:611597. [PMID: 33767656 PMCID: PMC7985080 DOI: 10.3389/fneur.2021.611597] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/16/2021] [Indexed: 01/15/2023] Open
Abstract
Background: In our previous single-center study of autoimmune encephalitis (AE) related autoantibody test results we found positivity in 60 patients out of 1,034 with suspected AE from 2012 through 2018 as part of a Hungarian nationwide program. In our current multicenter retrospective study, we analyzed the clinical characteristics and outcome of AE patients with positive neuronal cell surface autoantibody test results. Methods: A standard online questionnaire was used to collect demographic and clinical characteristics, laboratory and imaging data, therapy and prognosis of 30 definitive AE patients in four major clinical centers of the region. Results: In our study, 19 patients were positive for anti-NMDAR (63%), 6 patients (20%) for anti-LGI1, 3 patients for anti-GABABR (10%) and 3 patients for anti-Caspr2 (10%) autoantibodies. Most common prodromal symptoms were fever or flu-like symptoms (10/30, 33%). Main clinical features included psychiatric symptoms (83%), epileptic seizures (73%) and memory loss (50%). 19 patients (63%) presented with signs of central nervous system (CNS) inflammation, which occurred more frequently in elder individuals (p = 0.024), although no significant differences were observed in sex, tumor association, time to diagnosis, prognosis and immunotherapy compared to AE patients without CNS inflammatory markers. Anti-NMDAR encephalitis patients were in more severe condition at the disease onset (p = 0.028), although no significant correlation between mRS score, age, sex and immunotherapy was found. 27% of patients (n = 8) with associated tumors had worse outcome (p = 0.045) than patients without tumor. In most cases, immunotherapy led to clinical improvement of AE patients (80%) who achieved a good outcome (mRS ≤ 2; median follow-up 33 months). Conclusion: Our study confirms previous publications describing characteristics of AE patients, however, differences were observed in anti-NMDAR encephalitis that showed no association with ovarian teratoma and occurred more frequently among young males. One-third of AE patients lacked signs of inflammation in both CSF and brain MRI, which emphasizes the importance of clinical symptoms and autoantibody testing in diagnostic workflow for early introduction of immunotherapy, which can lead to favorable outcome in AE patients.
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Affiliation(s)
- Zsófia Hayden
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Beáta Bóné
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Gergely Orsi
- MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary.,Department of Neurosurgery, Clinical Centre, University of Pécs Medical School, Pécs, Hungary
| | - Monika Szots
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Nagy
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Tünde Csépány
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Zsolt Mezei
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Cecília Rajda
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Diána Simon
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - József Najbauer
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, BRIDGE, University of Southern Denmark, Odense, Denmark
| | - Timea Berki
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
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Broadley J, Wesselingh R, Seneviratne U, Kyndt C, Beech P, Buzzard K, Nesbitt C, D'souza W, Brodtmann A, Macdonell R, Kalincik T, Butzkueven H, O'Brien TJ, Monif M. Prognostic value of acute cerebrospinal fluid abnormalities in antibody-positive autoimmune encephalitis. J Neuroimmunol 2021; 353:577508. [PMID: 33588218 DOI: 10.1016/j.jneuroim.2021.577508] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the prognostic value of CSF abnormalities in seropositive autoimmune encephalitis (AE). METHODS We retrospectively studied 57 cases of seropositive AE. Primary outcomes were mortality and modified Rankin Scale, while secondary outcomes were first line treatment failure, ICU admission and relapse. Regression analysis was performed. RESULTS CSF white cell count (WCC) was higher in the NMDAR group, while elevated protein was more common amongst other subtypes. We found an association between WCC >5 cells/mm3 and treatment failure (OR 16.0, p = 0.006)), and between WCC >20 cells/mm3 and ICU admission (OR 19.3, p = 0.026). CONCLUSIONS Different subsets of AE have characteristic CSF abnormalities, which may aid recognition during early evaluation. CSF WCC had prognostic significance in our study.
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Affiliation(s)
- James Broadley
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Robb Wesselingh
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Udaya Seneviratne
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neuroscience, Monash Health, Melbourne, Australia; Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Chris Kyndt
- Department of Neurosciences, Eastern Health, Melbourne, Australia
| | - Paul Beech
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Radiology, Monash Health, Melbourne, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia
| | - Cassie Nesbitt
- Department of Neurology, Alfred Health, Melbourne, Australia; Department of Neuroscience, Barwon Health, Geelong, Australia
| | - Wendyl D'souza
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Amy Brodtmann
- Department of Neurosciences, Eastern Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Neurology, Austin Health, Melbourne, Australia
| | | | - Tomas Kalincik
- Department of Medicine, The University of Melbourne, Melbourne, Australia; CORe, The University of Melbourne, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, Monash University, Melbourne, Australia; Department of Neurology, Alfred Health, Melbourne, Australia; Department of Neurology, Melbourne Health, Melbourne, Australia; Department of Physiology, The University of Melbourne, Melbourne, Australia.
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Day GS, Gordon BA, Bucelli RC, Perrin RJ, Lopez-Chiriboga AS, Ances BM. Leveraging molecular biomarkers to make the common diagnosis in the uncommon patient. J Neuroimmunol 2021; 352:577474. [PMID: 33461093 DOI: 10.1016/j.jneuroim.2021.577474] [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: 11/05/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE The factors that predispose to relapse in patients recovering with autoimmune encephalitis (AE) are largely unknown, complicating efforts to distinguish patients with resurgent symptoms who may benefit from additional immune-modulating therapies from those with other causes of impairment. METHODS We report a patient with AE with leucine-rich glioma-inactivated 1 autoantibodies with a typical presentation, but atypical course complicated by treatment-refractory psychoses and progressive cognitive decline. We leveraged emergent molecular biomarkers, including [18F]florbetapir (amyloid) and [18F]flortaucipir AV45 (tau) PET neuroimaging, to evaluate for common neurodegenerative causes of impairment. The patient was followed until death and a brain autopsy performed. RESULTS No evidence of active inflammation was observed on neuroimaging or cerebrospinal fluid analyses in our patient with resurgent, treatment-refractory cognitive decline. [18F]Florbetapir and [18F]flortaucipir retention were increased in cerebral cortices in a pattern consistent with symptomatic Alzheimer's disease. Immunomodulatory therapies were stopped, and appropriate counseling provided to the patient and family. The patient died 2.4 months following [18F]flortaucipir PET neuroimaging. Brain autopsy confirmed changes typical of Alzheimer's disease without evidence of active inflammation or sequelae of AE, establishing Alzheimer's disease as the likely cause of resurgent symptoms in this patient. CONCLUSIONS Symptoms of age-related neurodegenerative illnesses may emerge following AE, particularly in older patients in whom neurodegenerative dementing illnesses are more common. Molecular biomarkers may aid in the evaluation of treatment-refractory patients with resurgent symptoms and signs, influencing management.
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Affiliation(s)
- Gregory S Day
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, United States of America.
| | - Brian A Gordon
- Washington University School of Medicine, Saint Louis, MO, United States of America; Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States of America
| | - Robert C Bucelli
- Washington University School of Medicine, Saint Louis, MO, United States of America; Department of Neurology, Washington University School of Medicine, United States of America
| | - Richard J Perrin
- Washington University School of Medicine, Saint Louis, MO, United States of America; Department of Neurology, Washington University School of Medicine, United States of America; Department of Pathology and Immunology, Washington University School of Medicine, United States of America
| | | | - Beau M Ances
- Washington University School of Medicine, Saint Louis, MO, United States of America; Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States of America; Department of Neurology, Washington University School of Medicine, United States of America
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Kao YC, Lin MI, Weng WC, Lee WT. Neuropsychiatric Disorders Due to Limbic Encephalitis: Immunologic Aspect. Int J Mol Sci 2020; 22:ijms22010389. [PMID: 33396564 PMCID: PMC7795533 DOI: 10.3390/ijms22010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Limbic encephalitis (LE) is a rare cause of encephalitis presenting as an acute and subacute onset of neuropsychiatric manifestations, particularly with memory deficits and confusion as core features, along with seizure occurrence, movement disorders, or autonomic dysfunctions. LE is caused by neuronal antibodies targeting the cellular surface, synaptic, and intracellular antigens, which alter the synaptic transmission, especially in the limbic area. Immunologic mechanisms involve antibodies, complements, or T-cell-mediated immune responses in different degree according to different autoantibodies. Sensitive cerebrospinal fluid markers of LE are unavailable, and radiographic findings may not reveal a typical mesiotemporal involvement at neurologic presentations; therefore, a high clinical index of suspicions is pivotal, and a neuronal antibody testing is necessary to make early diagnosis. Some patients have concomitant tumors, causing paraneoplastic LE; therefore, tumor survey and treatment are required in addition to immunotherapy. In this study, a review on the molecular and immunologic aspects of LE was conducted to gain awareness of its peculiarity, which we found quite different from our knowledge on traditional psychiatric illness.
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Affiliation(s)
- Yu-Chia Kao
- Department of Pediatrics, E-Da Hospital, Kaohsiung 82445, Taiwan;
| | - Ming-I Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71545); Fax: +886-2-23147450
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