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Fong SL, Dy Closas AMF, Lim TT, Lean PL, Loh EC, Lim SY, Tan AH. From parasomnia to agrypnia excitata - An illustrative case on diagnostic approach. Parkinsonism Relat Disord 2023; 109:105332. [PMID: 36948111 DOI: 10.1016/j.parkreldis.2023.105332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 03/06/2023]
Abstract
The diagnostic approach to sleep-related movements disorders is seldom discussed. We report a case of fatal familial insomnia who initially presented with persistent limb movements in sleep, which later progressed to a state of agrypnia excitata. Here, the evaluation of abnormal movements in sleep is discussed using a step-by-step diagnostic approach. Although no cure is available for fatal familial insomnia, prompt recognition of this condition is important to facilitate proper management, including the involvement of interdisciplinary neuropalliative care.
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Affiliation(s)
- Si-Lei Fong
- Division of Neurology, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Alfand Marl F Dy Closas
- Division of Neurology, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | - Phooi Leng Lean
- Department of Medicine, Seberang Jaya Hospital, Penang, Malaysia
| | - Ee Chin Loh
- Division of Palliative Medicine, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ai Huey Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
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Helmstaedter C, Hansen N, Leelaarporn P, Schwing K, Oender D, Widman G, Racz A, Surges R, Becker A, Witt JA. Specific B- and T-cell populations are associated with cognition in patients with epilepsy and antibody positive and negative suspected limbic encephalitis. J Neurol 2021; 268:455-466. [PMID: 32816110 PMCID: PMC7880943 DOI: 10.1007/s00415-020-10158-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neuropsychological impairments are major symptoms of autoimmune limbic encephalitis (LE) epilepsy patients. In LE epilepsy patients with an autoimmune response against intracellular antigens as well as in antibody-negative patients, the antibody findings and magnetic resonance imaging pathology correspond poorly to the clinical features. Here, we evaluated whether T- and B-cells are linked to cognitive impairment in these groups. METHODS In this cross-sectional, observational, case-controlled study, we evaluated 106 patients with adult-onset epilepsies with a suspected autoimmune etiology. We assessed verbal and visual memory, executive function, and mood in relation to the presence or absence of known auto-antibodies, and regarding T- and B-cell activity as indicated by flow cytometry (fluorescence-activated cell sorting = FACS, peripheral blood = PB and cerebrospinal fluid = CSF). RESULTS 56% of the patients were antibody-negative. In the other patients, auto-antibodies were directed against intracellular antigens (GAD65, paraneoplastic: 38%), or cellular surface antigens (LGI1/CASPR2/NMDA-R: 6%). Excluding LGI1/CASPR2/NMDA-R, the groups with and without antibodies did not differ in disease features, cognition, or mood. CD4+ T-cells and CD8+ T-cells in blood and CD4+ T-cells in CSF were prominent in the auto-antibody positive group. Regression analyses indicated the role education, drug load, amygdala and/or hippocampal pathology, and CD4+ T-cells play in verbal memory and executive function. Depressed mood revealed no relation to flow cytometry results. CONCLUSION Our results indicate a link between T- and B-cell activity and cognition in epilepsy patients with suspected limbic encephalitis, thus suggesting that flow cytometry results can provide an understanding of cognitive impairment in LE patients with autoantibodies against intracellular antigens.
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Affiliation(s)
- Christoph Helmstaedter
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Niels Hansen
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Pitshaporn Leelaarporn
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Kerstin Schwing
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Demet Oender
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Guido Widman
- SEIN Epilepsy Center, Hemsteede, The Netherlands
| | - Attila Racz
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital, Bonn, Germany
| | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Building 83 Venusberg-Campus 1, 53127, Bonn, Germany
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Devine MF, St Louis EK. Sleep Disturbances Associated with Neurological Autoimmunity. Neurotherapeutics 2021; 18:181-201. [PMID: 33786802 PMCID: PMC8116412 DOI: 10.1007/s13311-021-01020-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 12/29/2022] Open
Abstract
Associations between sleep disorders and neurological autoimmunity have been notably expanding recently. Potential immune-mediated etiopathogenesis has been proposed for various sleep disorders including narcolepsy, Kleine-Levin syndrome, and Morvan syndrome. Sleep manifestations are also common in various autoimmune neurological syndromes, but may be underestimated as overriding presenting (and potentially dangerous) neurological symptoms often require more urgent attention. Even so, sleep dysfunction has been described with various neural-specific antibody biomarkers, including IgLON5; leucine-rich, glioma-inactivated protein 1 (LGI1); contactin-associated protein 2 (CASPR2); N-methyl-D-aspartate (NMDA)-receptor; Ma2; dipeptidyl-peptidase-like protein-6 (DPPX); alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R); anti-neuronal nuclear antibody type-1 (ANNA-1, i.e., Hu); anti-neuronal nuclear antibody type-2 (ANNA-2, i.e., Ri); gamma-aminobutyric acid (GABA)-B-receptor (GABA-B-R); metabotropic glutamate receptor 5 (mGluR5); and aquaporin-4 (AQP-4). Given potentially distinctive findings, it is possible that sleep testing could potentially provide objective biomarkers (polysomnography, quantitative muscle activity during REM sleep, cerebrospinal fluid hypocretin-1) to support an autoimmune diagnosis, monitor therapeutic response, or disease progression/relapse. However, more comprehensive characterization of sleep manifestations is needed to better understand the underlying sleep disruption with neurological autoimmunity.
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Affiliation(s)
- Michelle F Devine
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA.
- Olmsted Medical Center, MN, Rochester, USA.
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Erik K St Louis
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Rochester, MN, USA
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Kuehn JC, Meschede C, Helmstaedter C, Surges R, von Wrede R, Hattingen E, Vatter H, Elger CE, Schoch S, Becker AJ, Pitsch J. Adult-onset temporal lobe epilepsy suspicious for autoimmune pathogenesis: Autoantibody prevalence and clinical correlates. PLoS One 2020; 15:e0241289. [PMID: 33119692 PMCID: PMC7595292 DOI: 10.1371/journal.pone.0241289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/13/2020] [Indexed: 02/08/2023] Open
Abstract
Temporal lobe adult-onset seizures (TAOS) related to autoimmunity represent an increasingly recognized disease syndrome within the spectrum of epilepsies. In this context, certain autoantibodies (autoABs) were often associated with limbic encephalitis (LE). Here, we aimed to gain insights into (a) the distribution of ‘neurological’ autoABs (neuroABs, defined as autoABs targeting neuronal surface structures or ‘onconeuronal’ ABs or anti-glutamate acid decarboxylase 65 (GAD65) autoABs) in a large consecutive TAOS patient cohort, to characterize (b) clinical profiles of seropositive versus seronegative individuals and to find (c) potential evidence for other autoABs. Blood sera/cerebrospinal fluid (CSF) of TAOS patients (n = 800) and healthy donors (n = 27) were analyzed for neuroABs and screened for other autoABs by indirect immunofluorescence on hippocampal/cerebellar sections and immunoblots of whole brain and synaptosome lysates. Serological results were correlated with clinico-neuropsychological features. 13% of TAOS patients (n = 105) were neuroAB+, with anti-GAD65 and anti-N-methyl-D-aspartate receptors (NMDAR) as most frequent autoABs in this group. In our screening tests 25% of neuroAB- patients (n = 199) were positive (screening+), whereas all control samples were negative (n = 27). Intriguingly, key clinico-neuropsychological characteristics including magnetic resonance imaging (MRI) findings, epileptiform electroencephalographic (EEG) activity, and inflammatory cellular infiltrates in CSF were shared to a greater extent by neuroAB+ with neuroAB-/screening+ patients than with neuroAB-/screening- patients. Serological testing in a large consecutive TAOS patient series revealed seropositivity for anti-GAD65 autoABs as the most frequent neuroAB. Intriguingly, neuroAB+ individuals were virtually indistinguishable from neuroAB-/screening+ patients in several major clinical features. In contrast, neuroAB-/screening- TAOS patients differed in many parameters. These data support the potential presence of so far unrecognized autoABs in patients with TAOS.
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Affiliation(s)
- Julia C. Kuehn
- Section for Translational Epilepsy Research, Dept. of Neuropathology, University Hospital Bonn, Bonn, Germany
| | | | - Christoph Helmstaedter
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Randi von Wrede
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Elke Hattingen
- Dept. of Neuroradiology, University Clinic of Frankfurt, Frankfurt, Germany
| | - Hartmut Vatter
- Clinic for Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Christian E. Elger
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Susanne Schoch
- Section for Translational Epilepsy Research, Dept. of Neuropathology, University Hospital Bonn, Bonn, Germany
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Albert J. Becker
- Section for Translational Epilepsy Research, Dept. of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Julika Pitsch
- Section for Translational Epilepsy Research, Dept. of Neuropathology, University Hospital Bonn, Bonn, Germany
- Dept. of Epileptology, University Hospital Bonn, Bonn, Germany
- * E-mail:
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