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Mori T, Matsuda S, Nishida H, Kohyama K, Fukuda M, Sakuma H. Paediatric antibody prevalence in seizure score to predict autoimmune aetiology in seizure disorders. Dev Med Child Neurol 2024. [PMID: 38641898 DOI: 10.1111/dmcn.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 04/21/2024]
Abstract
AIM To modify the antibody prevalence in epilepsy (APE) score of children with suspected autoimmune central nervous system disease with seizures. METHODS We retrospectively analysed the cerebrospinal fluid of 157 children (aged 0-18 years) with suspected autoimmune central nervous system disease for antineuronal antibodies in our laboratory from 2016 to 2023. Participants were randomly divided into the development cohort (n = 79, 35 females; median 7 years, SD 4 years 7 months, range 4-11 years) and validation cohort (n = 78, 28 females; median 7 years, SD 4 years 5 months, range 4-12 years). A paediatric antibody prevalence in seizure (PAPS) score was created for one cohort and evaluated in the other. Seven variables were selected through univariate and multivariate analysis to create a PAPS score. RESULTS One hundred and fifty-seven children who fulfilled the inclusion criteria were enrolled; 49 tested positive for antineuronal antibodies. The sensitivity and specificity of an APE score of 4 and greater were 92% and 22.2% respectively; the sensitivity and specificity of a PAPS score of 2.5 and greater were 83.3% and 77.8% respectively. The area under the curve was 0.832 (95% confidence interval = 0.743-0.921), which was significantly better than that for the APE score (p < 0.001). INTERPRETATION The APE score had high sensitivity but low specificity in children. The PAPS score may be useful for determining the need for antineuronal antibody testing.
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Affiliation(s)
- Takayuki Mori
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Shimpei Matsuda
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Hiroya Nishida
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Kuniko Kohyama
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
| | - Mitsumasa Fukuda
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hiroshi Sakuma
- Department of Brain & Neurosciences, Tokyo metropolitan Institute of Medical Science, Tokyo, Japan
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Zhou K, Zhang L, Shen S, Lin JF, Wang JR, Zhou D, Li JM, Sima X. Neurological autoantibody prevalence in chronic epilepsy: Clinical and neuropathologic findings. Seizure 2024; 115:28-35. [PMID: 38183825 DOI: 10.1016/j.seizure.2023.12.018] [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: 09/24/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND We aimed to explore the prevalence of autoimmune antibodies (Abs) in a large consecutive series with "chronic" epilepsy and without symptoms of autoimmune encephalitis; and to compare the immunopathology of brain tissue from drug-resistant epilepsy (DRE) with and without Abs positivity. METHODS Neuronal and glial antibodies were detected in the serum of patients who were admitted to the wards of West China Hospital from October 2016 to September 2019 and had epilepsy by cell-based assays and tissue-based assays. RESULTS Twenty-one (6.8 %) of 328 patients had positive Ab findings for the following: dipeptidyl-peptidase-like protein-6 (n = 7), contactin-associated protein-like 2 (n = 5), glutamic acid decarboxylase 65 (n = 4), gamma aminobutyric acid beta receptor (n = 2), N-methyl-d-aspartate receptor (n = 2), and dopamine D2 receptor (n = 1). Antibodies were detected in 6.9 % (13/187) of epilepsy people with unknown etiology and 5.6 % (8/141) of patients with known etiology, respectively. Among 190 patients with DRE, 14 (7.3 %) patients were Abs-positive. There was no significant difference between individuals with seropositive and seronegative results in clinical manifestations, except that the history of febrile seizure was significantly more frequent in the seropositive group. Moreover, brain samples from 3 patients with Abs-positive DRE (with DPPX in 2 patients, and CASPR2 in 1 patient) and 18 patients with Abs-negative DRE were analyzed for immunopathology. We found higher expression of CD8-positive T-cells in the hippocampus of Abs-positive DRE group. CONCLUSIONS Neuronal antibodies are potentially involved in the process of "chronic" epilepsy, and CD8-positive T-cells may play an important role in this process.
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Affiliation(s)
- Kui Zhou
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Le Zhang
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Sisi Shen
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jing-Fang Lin
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jie-Rui Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan 610041, China.
| | - Xiutian Sima
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Levite M, Goldberg H. Autoimmune Epilepsy - Novel Multidisciplinary Analysis, Discoveries and Insights. Front Immunol 2022; 12:762743. [PMID: 35095841 PMCID: PMC8790247 DOI: 10.3389/fimmu.2021.762743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Epilepsy affects ~50 million people. In ~30% of patients the etiology is unknown, and ~30% are unresponsive to anti-epileptic drugs. Intractable epilepsy often leads to multiple seizures daily or weekly, lasting for years, and accompanied by cognitive, behavioral, and psychiatric problems. This multidisciplinary scientific (not clinical) 'Perspective' article discusses Autoimmune Epilepsy from immunological, neurological and basic-science angles. The article includes summaries and novel discoveries, ideas, insights and recommendations. We summarize the characteristic features of the respective antigens, and the pathological activity in vitro and in animal models of autoimmune antibodies to: Glutamate/AMPA-GluR3, Glutamate/NMDA-NR1, Glutamate/NMDA-NR2, GAD-65, GABA-R, GLY-R, VGKC, LGI1, CASPR2, and β2 GP1, found in subpopulations of epilepsy patients. Glutamate receptor antibodies: AMPA-GluR3B peptide antibodies, seem so far as the most exclusive and pathogenic autoimmune antibodies in Autoimmune Epilepsy. They kill neural cells by three mechanisms: excitotoxicity, Reactive-Oxygen-Species, and complement-fixation, and induce and/or facilitate brain damage, seizures, and behavioral impairments. In this article we raise and discuss many more topics and new insights related to Autoimmune Epilepsy. 1. Few autoimmune antibodies tilt the balance between excitatory Glutamate and inhibitory GABA, thereby promoting neuropathology and epilepsy; 2. Many autoantigens are synaptic, and have extracellular domains. These features increase the likelihood of autoimmunity against them, and the ease with which autoimmune antibodies can reach and harm these self-proteins. 3. Several autoantigens have 'frenetic character'- undergoing dynamic changes that can increase their antigenicity; 4. The mRNAs of the autoantigens are widely expressed in multiple organs outside the brain. If translated by default to proteins, broad spectrum detrimental autoimmunity is expected; 5. The autoimmunity can precede seizures, cause them, and be detrimental whether primary or epiphenomenon; 6. Some autoimmune antibodies induce, and associate with, cognitive, behavioral and psychiatric impairments; 7. There are evidences for epitope spreading in Autoimmune Epilepsy; 8. T cells have different 'faces' in the brain, and in Autoimmune Epilepsy: Normal T cells are needed for the healthy brain. Normal T cells are damaged by autoimmune antibodies to Glutamate/AMPA GluR3, which they express, and maybe by additional autoantibodies to: Dopamine-R, GABA-R, Ach-R, Serotonin-R, and Adrenergic-R, present in various neurological diseases (summarized herein), since T cells express all these Neurotransmitter receptors. However, autoimmune and/or cytotoxic T cells damage the brain; 9. The HLA molecules are important for normal brain function. The HLA haplotype can confer susceptibility or protection from Autoimmune Epilepsy; 10. There are several therapeutic strategies for Autoimmune Epilepsy.
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Affiliation(s)
- Mia Levite
- Faculty of Medicine, The Hebrew University, Jerusalem, Israel
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Hadassa Goldberg
- Epilepsy Center, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Wang Y, Zhang WH, Wang Y. Case Report: Isolated Epileptic Seizures Associated With Anti-LGI1 Antibodies in a 7-Year-Old Girl With Literature Review. Front Pediatr 2022; 10:856775. [PMID: 35712617 PMCID: PMC9194368 DOI: 10.3389/fped.2022.856775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/09/2022] [Indexed: 12/20/2022] Open
Abstract
We describe the case of a 7-year-old girl with anti-leucine-rich glioma-inactivated 1 (anti-LGI1) antibodies (Abs) who presented with isolated epileptic seizures. Her refractory focal seizures did not respond to anti-seizure medicines but responded rapidly to immunotherapy. She remained seizure-free at 2 years follow-up. Reviewing the literature, isolated epileptic seizures have not been reported as the phenotype of anti-LGI1 autoimmunity in children. Our study indicated that screening for anti-LGI1 Abs is necessary for children with severe and/or drug-resistant new-onset focal epileptic seizures.
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Affiliation(s)
- Ying Wang
- Department of Neurology, Henan Children's Hospital, Zhengzhou Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Wei-Hua Zhang
- National Centre for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yuan Wang
- Department of Neurology, Henan Children's Hospital, Zhengzhou Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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Glial fibrillary acidic protein (GFAP)-antibody in children with focal seizures of undetermined cause. Acta Neurol Belg 2021; 121:1275-1280. [PMID: 32333263 DOI: 10.1007/s13760-020-01361-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/15/2020] [Indexed: 12/18/2022]
Abstract
Anti-neuronal antibodies that are related with autoimmune encephalitis syndromes may also be found in children with new onset seizures or chronic epilepsy. To unravel the significance of autoimmune astrocytopathy in epilepsy, we investigated serum antibody to glial fibrillary acidic protein (GFAP), another autoantigen described in autoimmune encephalitis with seizures, in 38 children with focal seizures of undetermined cause. GFAP antibody was screened with cell based assay and indirect immunohistochemistry and was found in two boys with normal brain MRI and unrevealing medical history prior to seizures. The 2-year-old boy had chronic treatment-resistant frontal lobe epilepsy. The 2.5-year-old boy had a single episode of focal seizures and remained seizure free thereafter in a follow-up period of 4 years. Nevertheless, he showed severe cognitive and language impairment. These results suggest that autoimmune astrocytopathy may be present in some epilepsy patients. Whether this immune response is a bystander effect generated by seizure-induced astrocytosis or directly involved in epileptogenesis needs to be further studied.
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Abdelsalam M, Abd Elmagid DS, Magdy H, El-Sabbagh AM, Mostafa M. The association between toll-like receptor 4 (TLR4) genotyping and the risk of epilepsy in children. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020. [DOI: 10.1186/s43042-020-00102-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Abstract
Background
Epilepsy is one of the most widely recognized neurological disorders; unfortunately, twenty to thirty percent of patients do not get cured from epilepsy, despite many trials of antiepileptic drug (AED) therapy. Immunotherapy may be a viable treatment strategy in a subset of epileptic patients. The association between Toll-like receptor polymorphisms and epilepsy clarifies the role of the immune system in epilepsy and its response to the drug. Thus, this study will focus on the relation between TLR4 rs1927914, rs11536858, rs1927911SNPs, and epilepsy in an Egyptian case-control study to assess their link to antiepileptic drug response.
Results
According to TLR4 rs1927914, there is a significant association between the SNP and the development of epilepsy, as CC genotype is 15.3 times more at risk for developing epilepsy than TT genotype, and CT is 11.1 times more at risk for developing epilepsy than TT. Also, patients with CC genotypes are 6.3 times more at risk for developing primary epilepsy than TT genotype.
According to rs11536858, there is a significant association between cases and control groups, as AA genotypes are found to be more at risk for developing epilepsy than GG genotypes. Also, there is a statistically significant association between clonazepam resistance and rs11536858, as p value < 0.001* with the highest frequency of TT genotypes at 4.3%.
According to rs1927911, there are no significant results between the cases and the control groups or between drug-responsive and drug resistance.
Conclusion
Possible involvement of the Toll-like receptor clarifies the importance of innate immunity in initiating seizures and making neuronal hyperexcitability. In this work, multiple significant associations between TLR SNPs and epilepsy, epileptic phenotype, and drug-resistant epilepsy have been found. More studies with bigger sample sizes and different techniques with different SNPs are recommended to find the proper immunotherapy for epilepsy instead of the treatment by antiepileptic drugs.
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Symonds JD, Moloney TC, Lang B, McLellan A, O'Regan ME, MacLeod S, Jollands A, Vincent A, Kirkpatrick M, Brunklaus A, Shetty J, Dorris L, Forbes K, Abu-Arafeh I, Andrew J, Brink P, Callaghan M, Cruden J, Findlay C, Grattan R, MacDonnell J, McKnight J, Morrison CA, Nairn L, Pilley E, Stephen E, Thomsen S, Webb A, Wilson M, Zuberi SM. Neuronal antibody prevalence in children with seizures under 3 years: A prospective national cohort. Neurology 2020; 95:e1590-e1598. [PMID: 32690789 DOI: 10.1212/wnl.0000000000010318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/30/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report the prevalence of anti-neuronal antibodies in a prospective whole-nation cohort of children presenting with seizures before their third birthday. METHODS This was a prospective population-based national cohort study involving all children presenting with new-onset epilepsy or complex febrile seizures before their third birthday over a 3-year period. Patients with previously identified structural, metabolic, or infectious cause for seizures were excluded. Serum samples were obtained at first presentation and tested for 7 neuronal antibodies using live cell-based assays. Clinical data were collected with structured proformas at recruitment and 24 months after presentation. In addition, patients with seizures and clinically suspected autoimmune encephalitis were independently identified by a review of the case records of all children <3 years of age in Scotland who had undergone EEG. RESULTS Two hundred ninety-eight patients were identified and recruited and underwent autoantibody testing. Antibody positivity was identified in 18 of 298 (6.0%). The antibodies identified were GABA receptor B (n = 8, 2.7%), contactin-associated protein 2 (n = 4, 1.3%), glycine receptor (n = 3, 1.0%), leucine-rich glioma inactivated 1 (n = 2, 0.7%), NMDA receptor (n = 1, 0.3%), and GABA receptor A (n = 1, 0.3%). None of these patients had a clinical picture of autoimmune encephalitis. Seizure classification and clinical phenotype did not correlate with antibody positivity. CONCLUSIONS Autoimmune encephalitis is very rare in early childhood. However serum neuronal antibodies are identified in 6.4% of children presenting with seizures at <3 years of age. Antibody testing should not be a routine clinical test in early childhood-onset epilepsy because, in the absence of other features of autoimmune encephalitis, antibody positivity is of doubtful clinical significance. Antibody testing should be reserved for patients with additional features of encephalitis.
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Affiliation(s)
- Joseph D Symonds
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Teresa C Moloney
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Bethan Lang
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Ailsa McLellan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Mary E O'Regan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Stewart MacLeod
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Alice Jollands
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Angela Vincent
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Martin Kirkpatrick
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Andreas Brunklaus
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jayakara Shetty
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Liam Dorris
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Kirsten Forbes
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Ishaq Abu-Arafeh
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jamie Andrew
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Philip Brink
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Mary Callaghan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jamie Cruden
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Christine Findlay
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Rosemary Grattan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jane MacDonnell
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jean McKnight
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Calum A Morrison
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Lesley Nairn
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Elizabeth Pilley
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Elma Stephen
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Selina Thomsen
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Alan Webb
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Margaret Wilson
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Sameer M Zuberi
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK.
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Syrbe S, Stettner GM, Bally J, Borggraefe I, Bien CI, Ferfoglia RI, Huppke P, Kern J, Polster T, Probst-Müller E, Schmid S, Steinfeld R, Strozzi S, Weichselbaum A, Weitz M, Ziegler A, Wandinger KP, Leypoldt F, Bien CG. CASPR2 autoimmunity in children expanding to mild encephalopathy with hypertension. Neurology 2020; 94:e2290-e2301. [PMID: 32424051 DOI: 10.1212/wnl.0000000000009523] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/12/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To delineate autoimmune disease in association with contactin-associated protein 2 (CASPR2) antibodies in childhood, we reviewed the clinical phenotype of children with CASPR2 antibodies. METHODS Retrospective assessment of patients recruited through laboratories specialized in autoimmune CNS disease. RESULTS Ten children with serum CASPR2 antibodies were identified (age at manifestation 18 months to 17 years). Eight children with CASPR2 antibody titers from ≥1:160 to 1:5,120 had complex autoimmune diseases with an age-dependent clinical phenotype. Two children with structural epilepsy due to CNS malformations harbored nonspecific low-titer CASPR2 antibodies (serum titers 1:80). The clinical symptoms of the 8 children with high-titer CASPR2 antibodies were general weakness (8/8), sleep dysregulation (8/8), dysautonomia (8/8) encephalopathy (7/8), neuropathic pain (7/8), neuromyotonia (3/8), and flaccid paresis (3/8). Adolescents (3/8) showed pain, neuromyotonia, and encephalopathy, whereas younger children (5/8) displayed severe hypertension, encephalopathy, and hormonal dysfunction mimicking a systemic disease. No tumors were identified. Motor symptoms remitted with immunotherapy. Mild behavioral changes persisted in 1 child, and autism spectrum disorder was diagnosed during follow-up in a young boy. CONCLUSION High-titer CASPR2 antibodies are associated with Morvan syndrome in children as young as 2 years. However, CASPR2 autoimmunity mimics systemic disease and hypertensive encephalopathy in children younger than 7 years. The outcome following immunotherapy was mostly favorable; long-term behavioral impairment may occur in younger children.
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Affiliation(s)
- Steffen Syrbe
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany.
| | - Georg M Stettner
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Julien Bally
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Ingo Borggraefe
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Corinna I Bien
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Ruxandra Iancu Ferfoglia
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Peter Huppke
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Jan Kern
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Tilman Polster
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Elisabeth Probst-Müller
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Silvia Schmid
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Robert Steinfeld
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Susi Strozzi
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Annette Weichselbaum
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Marcus Weitz
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Andreas Ziegler
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Klaus-Peter Wandinger
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Frank Leypoldt
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
| | - Christian G Bien
- From the Division of Pediatric Epileptology (S. Syrbe), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Germany; Division of Pediatric Neurology (G.M.S., R.S.), University Children's Hospital Zurich; Department of Neurology (J.B., R.I.F.), University & University Hospitals of Geneva, Switzerland; Division of Pediatric Neurology (I.B.), Developmental Neurology and Social Pediatrics, Department of Pediatrics and Epilepsy Center for Children, Adolescents and Adults, University Hospital LMU Munich; Laboratory Krone (C.I.B., C.G.B.), Bad Salzuflen; Department of Pediatrics and Pediatric Neurology (P.H.), Faculty of Medicine, Georg August University, Goettingen; Department of Child Neurology (J.K., A.W.), University Children's Hospital, Tuebingen; Epilepsy Center Bethel (T.P., C.G.B.), Krankenhaus Mara, Bielefeld, Germany; Clinic of Immunology (E.P.-M.), University Hospital Zurich; Kantonsspital Graubünden (S. Schmid, S. Strozzi), Chur; Pediatric Nephrology Unit (M.W.), University Children's Hospital Zurich, Switzerland; Division of Child Neurology and Metabolic Medicine (A.Z.), Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg; Institute of Clinical Chemistry (K.-P.W., F.L.), Neuroimmunology Section, University Hospital Schleswig-Holstein Kiel/Lübeck; Department of Neurology (K.-P.W.), University of Lübeck; and Department of Neurology (F.L.), Christian-Albrechts-University Kiel, Germany
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9
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Zelano J, Axelsson M, Constantinescu R, Malmeström C, Kumlien E. Neuronal antibodies in adult patients with new-onset seizures: A prospective study. Brain Behav 2019; 9:e01442. [PMID: 31588654 PMCID: PMC6851805 DOI: 10.1002/brb3.1442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/14/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Immunotherapy in addition to antiepileptic drugs can improve seizure freedom rates in autoimmune epilepsy, highlighting the importance of early diagnosis. A diagnosis of autoimmune epilepsy can be supported by presence of serum antibodies to neuronal antigens. We asked how often neuronal antibodies are found in the serum of unselected adult patients with new-onset seizures and whether such testing could improve detection of autoimmune epilepsy. MATERIAL AND METHODS We included 44 patients over the age of 25 presenting after at least one unprovoked seizure to the Neurology Clinic at Sahlgrenska University Hospital, Gothenburg, Sweden. The median time between the first-ever seizure in life and the serum sampling was 50 days (range 22-11,000). Antibody testing in serum was performed according to the manufacturer's instructions. The patients were followed for at least 1 year. RESULTS Epilepsy could be diagnosed already at the first visit in 21/44 patients (47.7%). Two patients (4.5%) were positive for neuronal antibodies: one against contactin-associated protein 2 (CASPR-2) and one against glutamate acid decarboxylase (GAD). Three patients (6.7%) displayed very weak immunoreactivity that was deemed clinically insignificant. One of the antibody-positive patients had only a single seizure. The other had a focal cortical dysplasia and was seizure-free on levetiracetam. None of the five patients with antibodies or immunoreactivity displayed any feature of autoimmune epilepsy. CONCLUSIONS We conclude that indiscriminate testing in patients presenting to a first seizure clinic with new-onset seizures or epilepsy is unlikely to improve detection of autoimmune epilepsy.
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Affiliation(s)
- Johan Zelano
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Radu Constantinescu
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Clas Malmeström
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Laboratory for Clinical immunology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Kumlien
- Department of Neurology, Uppsala University, Uppsala, Sweden
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10
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Nosadini M, Toldo I, Tascini B, Bien CG, Parmeggiani L, De Gaspari P, Zuliani L, Sartori S. LGI1 and CASPR2 autoimmunity in children: Systematic literature review and report of a young girl with Morvan syndrome. J Neuroimmunol 2019; 335:577008. [DOI: 10.1016/j.jneuroim.2019.577008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
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11
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Relevance of Surface Neuronal Protein Autoantibodies as Biomarkers in Seizure-Associated Disorders. Int J Mol Sci 2019; 20:ijms20184529. [PMID: 31540204 PMCID: PMC6769659 DOI: 10.3390/ijms20184529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/13/2022] Open
Abstract
The detection of neuronal surface protein autoantibody-related disorders has contributed to several changes in our understanding of central nervous system autoimmunity. The clinical presentation of these disorders may be associated (or not) with tumors, and often patients develop an inexplicable onset of epilepsy, catatonic or autistic features, or memory and cognitive dysfunctions. The autoantigens in such cases have critical roles in synaptic transmission and plasticity, memory function, and process learning. For months, patients with such antibodies may be comatose or encephalopathic and yet completely recover with palliative care and immunotherapies. This paper reviews several targets of neuronal antibodies as biomarkers in seizure disorders, focusing mainly on autoantibodies, which target the extracellular domains of membrane proteins, namely leucine-rich glioma-inactivated-1 (LGI1), contactin-associated protein-like 2 (CASPR2), the N-methyl-D-aspartate receptor (NMDAR), γ-aminobutyric acid receptor-B (GABABR), the glycine receptor (GlyR), and a-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs). In order to restore health status, limit hospitalization, and optimize results, testing these antibodies should be done locally, using internationally certified procedures for a precise and rapid diagnosis, with the possibility of initiating therapy as soon as possible.
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12
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López-Chiriboga AS, Klein C, Zekeridou A, McKeon A, Dubey D, Flanagan EP, Lennon VA, Tillema JM, Wirrell EC, Patterson MC, Gadoth A, Aaen JG, Brenton JN, Bui JD, Moen A, Otten C, Piquet A, Pittock SJ. LGI1 and CASPR2 neurological autoimmunity in children. Ann Neurol 2019; 84:473-480. [PMID: 30076629 DOI: 10.1002/ana.25310] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/19/2023]
Abstract
The clinical phenotype of leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated proteinlike 2 (CASPR2) autoimmunity is well defined in adults. Data for children are limited (<10 cases). Among 13,319 pediatric patients serologically tested for autoimmune neurological disorders (2010-2017), 264 were seropositive for voltage-gated potassium channel-complex-IgG (radioimmunoprecipitation). Only 13 (4.9%) were positive by transfected cell-binding assay for LGI1-IgG (n = 7), CASPR2-IgG (n = 3), or both (n = 3). This is significantly less than in adults. Encephalopathy, seizures, and peripheral nerve hyperexcitability were common, as was coexisting autoimmunity. No faciobrachial dystonic seizures or cancers were identified. Functional neurologic disorders were frequently the initial diagnosis, and immunotherapy appeared beneficial. Ann Neurol 2018;84:473-480.
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Affiliation(s)
| | | | | | - Andrew McKeon
- Departments of Neurology.,Laboratory Medicine and Pathology
| | | | | | - Vanda A Lennon
- Departments of Neurology.,Laboratory Medicine and Pathology.,Immunology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - J Gregory Aaen
- Department of Pediatrics and Neurology, Loma Linda University Children's Hospital, Loma Linda, CA
| | - J Nicholas Brenton
- Department of Neurology and Pediatrics, University of Virginia, Charlottesville, VA
| | - Jonathan D Bui
- Department of Neurosciences, University of California, San Diego and Division of Child Neurology, Rady Children's Hospital, San Diego, CA
| | - Amanda Moen
- Department of Pediatric Neurology, Gillette Children's Specialty Healthcare, St Paul, MN
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA
| | - Amanda Piquet
- Department of Neurology, University of Colorado, Aurora, CO
| | - Sean J Pittock
- Departments of Neurology.,Laboratory Medicine and Pathology
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13
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Abstract
The field of autoimmune epilepsy has evolved substantially in the last few decades with discovery of several neural autoantibodies and improved mechanistic understanding of these immune-mediated syndromes. A considerable proportion of patients with epilepsy of unknown etiology have been demonstrated to have an autoimmune cause. The majority of the patients with autoimmune epilepsy usually present with new-onset refractory seizures along with subacute progressive cognitive decline and behavioral or psychiatric dysfunction. Neural specific antibodies commonly associated with autoimmune epilepsy include leucine-rich glioma-inactivated protein 1 (LGI1), N-methyl-D-aspartate receptor (NMDA-R), and glutamic acid decarboxylase 65 (GAD65) IgG. Diagnosis of these cases depends on the identification of the clinical syndrome and ancillary studies including autoantibody evaluation. Predictive models (Antibody Prevalence in Epilepsy and Encephalopathy [APE2] and Response to Immunotherapy in Epilepsy and Encephalopathy [RITE2] scores) based on clinical features and initial neurological assessment may be utilized for selection of cases for autoimmune epilepsy evaluation and management. In this article, we will review the recent advances in autoimmune epilepsy and provide diagnostic and therapeutic algorithms for epilepsies with suspected autoimmune etiology.
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Affiliation(s)
- Khalil S Husari
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Divyanshu Dubey
- Department of Neurology and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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14
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Liang W, Zhang J, Saint-Martin M, Xu F, Noraz N, Liu J, Honnorat J, Liu H. Structural mapping of hot spots within human CASPR2 discoidin domain for autoantibody recognition. J Autoimmun 2018; 96:168-177. [PMID: 30337146 DOI: 10.1016/j.jaut.2018.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/23/2018] [Accepted: 09/30/2018] [Indexed: 01/17/2023]
Abstract
Accumulating evidence has showed that anti-CASPR2 autoantibodies occur in a long list of neurological immune disorders including limbic encephalitis (LE). Belonging to the well-known neurexin superfamily, CASPR2 has been suggested to be a central node in the molecular networks controlling neurodevelopment. Distinct from other subfamilies in the neurexin superfamily, the CASPR subfamily features a unique discoidin (Disc) domain. As revealed by our and others' recent studies, CASPR2 Disc domain bears a major epitope for autoantibodies. However, structural information on CASPR2 recognition by autoantibodies has been lacking. Here, we report the crystal structure of human CASPR2 Disc domain at a high resolution of 1.31 Å, which is the first atomic-resolution structure of the CASPR subfamily members. The Disc domain adopts a total β structure and folds into a distorted jellyroll-like barrel with a conserved disulfide-bond interlocking its N- and C-termini. Defined by four loops and located in one end of the barrel, the "loop-tip surface" is totally polar and easily available for protein docking. Based on structure-guided epitope prediction, we generated nine mutants and evaluated their binding to autoantibodies of cerebrospinal fluid from twelve patients with limbic encephalitis. The quadruple mutant G69N/A71S/S77N/D78R impaired CASPR2 binding to autoantibodies from eleven LE patients, which indicates that the loop L1 in the Disc domain bears hot spots for autoantibody interaction. Structural mapping of autoepitopes within human CASPR2 Disc domain sheds light on how autoantibodies could sequester CASPR2 ectodomain and antagonize its functionalities in the pathogenic processes.
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Affiliation(s)
- Wenjun Liang
- State Key Laboratory of Natural and Biomimetic Drugs & School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China; Department of Molecular and Cellular Pharmacology, School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Junying Zhang
- State Key Laboratory of Natural and Biomimetic Drugs & School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China; Department of Molecular and Cellular Pharmacology, School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Margaux Saint-Martin
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; INSERM U1217-CNRS UMR5310, NeuroMyoGene Institute, Lyon, France; Université Claude Bernard Lyon 1, Université de Lyon, France
| | - Fei Xu
- State Key Laboratory of Natural and Biomimetic Drugs & School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China; Department of Molecular and Cellular Pharmacology, School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Nelly Noraz
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; INSERM U1217-CNRS UMR5310, NeuroMyoGene Institute, Lyon, France; Université Claude Bernard Lyon 1, Université de Lyon, France
| | - Jianmei Liu
- State Key Laboratory of Natural and Biomimetic Drugs & School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China; Department of Molecular and Cellular Pharmacology, School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; INSERM U1217-CNRS UMR5310, NeuroMyoGene Institute, Lyon, France; Université Claude Bernard Lyon 1, Université de Lyon, France.
| | - Heli Liu
- State Key Laboratory of Natural and Biomimetic Drugs & School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China; Department of Molecular and Cellular Pharmacology, School of Pharmaceutical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, China.
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15
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Garcia-Tarodo S, Datta AN, Ramelli GP, Maréchal-Rouiller F, Bien CG, Korff CM. Circulating neural antibodies in unselected children with new-onset seizures. Eur J Paediatr Neurol 2018; 22:396-403. [PMID: 29291919 DOI: 10.1016/j.ejpn.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/04/2017] [Accepted: 12/11/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The role of autoimmunity and neural antibodies is increasingly recognized in different forms of seizures and epilepsy. Their prevalence in new-onset epilepsy has also recently been the focus of several clinical cohorts in the adult and pediatric population, with positive titers in 10-11% of cases. Our aim was to determine the seropositivity at the first seizure onset in a non-selective group of children. METHOD We conducted a prospective multicenter cohort study recruiting children aged 0-16 years with new-onset seizures presenting at the In- and Outpatient Pediatric Neurology Departments of three Children's Hospitals in Switzerland between September 2013 and April 2016. Neural antibodies were screened within the first 6 months of a first seizure and when positive, repeated at 1 month and 6 months follow-up. RESULTS A total of 103 children were enrolled with a mean age at presentation of 5 years (range 1 day-15 years 9 months). The majority (n = 75) presented with generalized seizures and 6 had status epilepticus lasting > 30 min. At the time of onset, 55% of patients had fever, 24% required emergency seizure treatment and 27% hospitalization. Epilepsy was diagnosed at follow-up in 18%. No specific antibody was found. Serum antibodies against the VGKC complex, without binding to the specific antigens LGI1 and CASPR2, were found in two patients. Four patients harbored not otherwise characterized antibodies against mouse neuropil. INTERPRETATION Specific neural antibodies are rarely found in an unselected population of children that present with a first seizure. Applying an extensive neuronal antibody profile in a child with new-onset seizures does not appear to be justified.
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Affiliation(s)
- Stephanie Garcia-Tarodo
- Paediatric Neurology Unit, Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandre N Datta
- Department of Pediatric Neurology and Developmental Medicine, University of Basel, Children's Hospital, Basel, Switzerland
| | - Gian P Ramelli
- Department of Paediatrics, Regional Hospital San Giovanni, Bellinzona, Switzerland
| | | | | | - Christian M Korff
- Paediatric Neurology Unit, Children's Hospital, Geneva University Hospitals, Geneva, Switzerland.
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16
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Abstract
PURPOSE OF REVIEW The aim of this study was to assess the seizure manifestations and risk of epilepsy in encephalitis associated with antibodies against neuronal cell-surface (autoimmune encephalitis) or myelin-associated antigens, and to review several chronic epileptic disorders, including Rasmussen's encephalitis, fever-induced refractory epileptic syndromes (FIRES) and new-onset refractory status epilepticus (NORSE). RECENT FINDINGS Seizures are a frequent manifestation of autoimmune encephalitis. Some autoimmune encephalitis may associate with characteristic features: faciobrachial dystonic seizures (anti-LGI1 encephalitis), electroencephalogram extreme delta brush (anti-NMDAR) or multifocal FLAIR-MRI abnormalities (anti-GABAAR). In anti-LGI1 encephalitis, cortical, limbic and basal ganglia dysfunction results in different types of seizures. Autoimmune encephalitis or myelin-antibody associated syndromes are often immunotherapy-responsive and appear to have a low risk for chronic epilepsy. In contrast patients with seizures related to GAD65-antibodies (an intracellular antigen) frequently develop epilepsy and have suboptimal response to treatment (including surgery). Rasmussen's encephalitis or FIRES may occur with autoantibodies of unclear significance and rarely respond to immunotherapy. A study of patients with NORSE showed that 30% developed chronic epilepsy. SUMMARY Although seizures are frequent in all types of autoimmune encephalitis, the risk for chronic epilepsy is dependent on the antigen: lower if located on the cell-surface, and higher if intracellular. For other disorders (Rasmussen's encephalitis, FIRES, NORSE), the prognosis remains poor.
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17
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Abstract
Pediatric autoimmune epileptic encephalopathies are predominantly characterized by the presence of autoantibodies to the surface of neuronal proteins, for example, N-methyl-d-aspartate (NMDA) receptor antibodies, but also include diseases with non-cell surface antibodies (eg, anti-Hu, glutamic-acid decarboxylase antibodies). In some cases with distinct clinical and para-clinical features, an autoimmune epileptic encephalopathy can be diagnosed without the presence of an antibody and will also respond favorably to immunotherapy. In this review, we summarize the common presentations of pediatric autoimmune epileptic encephalopathies, treatments, and outcomes, and report recent findings in the field of epilepsy, encephalopathy, and the immune system.
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Affiliation(s)
- Sukhvir Wright
- 1 Department of Pediatric Neurology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Angela Vincent
- 2 Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, Oxford, United Kingdom
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18
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Abstract
OBJECTIVE Epilepsy is a chronic neurological disease characterised with seizures. The aetiology of the most generalised epilepsies cannot be explicitly determined and the seizures are pronounced to be genetically determined by disturbances of receptors in central nervous system. Besides, neurotransmitter distributions or other metabolic problems are supposed to involve in epileptogenesis. Lack of adequate data about pharmacological agents that have antiepileptogenic effects point to need of research on this field. Thus, in this review, inflammatory aspects of epileptogenesis has been focussed via considering several concepts like role of immune system, blood-brain barrier and antibody involvement in epileptogenesis. METHODS We conducted an evidence-based review of the literatures in order to evaluate the possible participation of inflammatory processes to epileptogenesis and also, promising agents which are effective to these processes. We searched PubMed database up to November 2015 with no date restrictions. RESULTS In the present review, 163 appropriate articles were included. Obtained data suggests that inflammatory processes participate to epileptogenesis in several ways like affecting fibroblast growth factor-2 and tropomyosin receptor kinase B signalling pathways, detrimental proinflammatory pathways [such as the interleukin-1 beta (IL-1β)-interleukin-1 receptor type 1 (IL-1R1) system], mammalian target of rapamycin pathway, microglial activities, release of glial inflammatory proteins (such as macrophage inflammatory protein, interleukin 6, C-C motif ligand 2 and IL-1β), adhesion molecules that are suggested to function in signalling pathways between neurons and microglia and also linkage between these molecules and proinflammatory cytokines. CONCLUSION The literature research indicated that inflammation is a part of epileptogenesis. For this reason, further studies are necessary for assessing agents that will be effective in clinical use for therapeutic treatment of epileptogenesis.
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19
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Mori T, Takahashi Y, Araya N, Oboshi T, Watanabe H, Tsukamoto K, Yamaguchi T, Yoshitomi S, Nasu H, Ikeda H, Otani H, Imai K, Shigematsu H, Inoue Y. Antibodies against peptides of NMDA-type GluR in cerebrospinal fluid of patients with epileptic spasms. Eur J Paediatr Neurol 2016; 20:865-873. [PMID: 27515477 DOI: 10.1016/j.ejpn.2016.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 06/21/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We investigated the contribution of antibodies against N-methyl-d-aspartate (NMDA)-type glutamate receptor (GluR) in cerebrospinal fluid (CSF) to the clinical features of patients with epileptic spasms (ES). METHODS CSF samples were collected from 33 patients with ES with median (range) age 1.8 (0.2-8.5) years. Thirty patients without ES with 3.5 (0.5-7.0) years were also studied as disease controls. The CSF levels of antibodies against peptides of NMDA-type GluR subunits (GluN2B & GluN1) were measured by enzyme-linked immunosorbent assay. RESULTS The levels of antibodies against the n-terminal of GluN2B (GluN2B-NT2), c-terminal of GluN2B (GluN2B-CT) and n-terminal of GluN1 (GluN1-NT), were significantly higher in patients with ES than in disease controls (p < 0.01, p < 0.01 & p = 0.03). Levels of antibodies to GluN2B-NT2 & CT were not related with ACTH therapy nor conventional CSF factors (cell counts, protein level, etc). Levels of antibodies to GluN2B-NT2 & CT showed evidence of correlation within a linear regression model with intervals from the onset to the examination of CSF until 25 months (p = 0.01 & p = 0.01). The correlation was significant in patients with unknown cause (p = 0.01). Five of 33 patients (four unknown cause & one chromosomal anomaly) had higher level of antibodies to GluN2B-NT2 exceeding mean + 1 SD of all ES patients, and they had poor motor (score 0) and cognitive outcomes (score 0 or 1). CONCLUSION The CSF level of antibodies against GluN2B in ES patients with unknown cause was estimated to increase after onset. We hypothesize that some ES patients may have immune process after the onset of ES.
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Affiliation(s)
- Tatsuo Mori
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan.
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Nami Araya
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Taikan Oboshi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Hirokazu Watanabe
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Kazuki Tsukamoto
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Tokito Yamaguchi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Shinsaku Yoshitomi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Hirosato Nasu
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Hiroko Ikeda
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Hideyuki Otani
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Katsumi Imai
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Hideo Shigematsu
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
| | - Yushi Inoue
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama, Aoi-ku, Shizuoka 420-8688, Japan
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Ude C, Ambegaonkar G. Glycine receptor antibody-associated epilepsy in a boy aged 4 years. BMJ Case Rep 2016; 2016:bcr-2016-216468. [PMID: 27797796 DOI: 10.1136/bcr-2016-216468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Our patient was a previously normal boy who presented to his local hospital with an explosive onset of prolonged seizures and encephalopathy. He was treated for a presumed central nervous system infection and initial neuroimaging was normal. Despite treatment with antibiotics and antiepileptic drugs (AEDs), he remained encephalopathic and became ataxic over the next 48 hours, not related to medication. The seizures also proved resistant to treatment despite polytherapy with AEDs, and he required immune-modulatory treatment, intravenous methylprednisolone and intravenous immunoglobulin, in addition to the AEDs to achieve seizure control. The ataxia also improved following treatment. The initial EEG was normal but subsequent EEGs, separated by a week each, were abnormal and revealed subtle atypical 'delta-brush-like waves'. The patient's serum and cerebrospinal fluid were tested for autoantibodies, and he was found to be positive for glycine receptor antibodies that are neuronal antibodies.
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Affiliation(s)
- Chinwe Ude
- Department of Paediatrics, Darent Valley Hospital, Dartford, Kent, UK
| | - Gautam Ambegaonkar
- Department of Paediatric Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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21
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Dubey D, Farzal Z, Hays R, Brown LS, Vernino S. Evaluation of positive and negative predictors of seizure outcomes among patients with immune-mediated epilepsy: a meta-analysis. Ther Adv Neurol Disord 2016; 9:369-77. [PMID: 27582892 DOI: 10.1177/1756285616656295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The objective of this study was to analyze published literature on autoimmune epilepsy and assess predictors of seizure outcome. METHODS From PubMed and EMBASE databases, two reviewers independently identified publications reporting clinical presentations, management and outcomes of patients with autoimmune epilepsy. A meta-analysis of 46 selected studies was performed. Demographic/clinical variables (sex, age, clinical presentation, epilepsy focus, magnetic resonance imaging [MRI] characteristics, time to diagnosis and initiation of immunomodulatory therapy, and type of immunomodulatory therapy) were compared between two outcome groups (responders and nonresponders). Clinical response was defined as >50% reduction in seizure frequency. Unstandardized effect sizes were collected for the studies for responder and nonresponder groups. Sample size was used as the weight in the meta-analysis. The random effects model was used to account for heterogeneity in the studies. RESULTS The 46 reports included 186 and 96 patients in responder and nonresponder groups respectively. Mean age of the responders and nonresponders was 43 and 31 years (p < 0.01). Responders were more likely to have cell-surface antibodies (68% versus 39%, p < 0.05), particularly voltage-gated potassium channel complex antibodies (p < 0.01). Mean duration from symptom onset to diagnosis, and symptom onset to initiation of immunomodulation was significantly lower among the responders (75 versus 431 days, p < 0.05, and 80 versus 554, p < 0.01, respectively). There was no outcome difference based on gender, MRI characteristics, seizure type, type of acute immunomodulatory therapy, or use of chronic immunomodulation. CONCLUSIONS Among published cases to date, older age, presence of cell-surface antibodies, early diagnosis and immunomodulatory treatment are associated with better seizure outcomes among patients with autoimmune epilepsy.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Zehra Farzal
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ryan Hays
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - L Steven Brown
- Department of Health Systems Research Parkland Health & Hospital System Dallas, TX, USA
| | - Steven Vernino
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
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Autoantibodies to neuronal antigens in children with focal epilepsy and no prima facie signs of encephalitis. Eur J Paediatr Neurol 2016; 20:573-9. [PMID: 27056280 DOI: 10.1016/j.ejpn.2016.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/07/2016] [Accepted: 03/12/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVE There is increasing awareness of neuronal autoantibodies and their impact on the pathogenesis of epilepsy. We investigated children with focal epilepsy in order to provide an estimate of autoantibody frequency within a pediatric population without prima facie evidence of encephalitis using a broad panel of autoantibodies. This was done to assess the specificity of antibodies and to see whether antibodies might be of modifying influence on the course of focal epilepsies. METHOD We searched for autoantibodies in 124 patients with focal epilepsy (1-18 years; mean 10; 6 years). Sera were tested using a broad panel of surface and intracellular antigens. RESULTS We found autoantibodies in 5/124 patients (4%): high-positive GAD65 antibodies (n = 1), low-positive GAD65 antibodies (N = 1), VGKC complex antibodies not reactive with LGI1 or CASPR2 (n = 3). We did not find any distinctive features distinguishing antibody positive patients from those without antibodies. CONCLUSIONS The antibodies found in this cohort are probably neither disease-specific nor pathogenic. This has been suggested before for these antigenic targets. Moreover, they do not seem to modify disease severity in the antibody-positive epilepsy patients.
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Abstract
PURPOSE OF REVIEW Autoimmune epileptic encephalopathy is a potentially treatable neurological syndrome characterized by the coexistence of a neuronal antibody in serum and, often, cerebrospinal fluid. Patients present with combinations of seizures, neuropsychiatric features, movement disorder, and cognitive decline, but some patients have isolated seizures either at first presentation or during their illness. This review summarizes our current understanding of the roles of specific neuronal antibodies in epilepsy-related syndromes and aims to aid the clinician in diagnosis and treatment. RECENT FINDINGS Antigen discovery methods in three neuroimmunology centres independently identified antibodies to different subunits of the γ amino butyric acid-A receptor; high levels of these antibodies were found mainly in patients with severe refractory seizures. These and other antibodies were also found in a proportion (<10%) of children and adults with epilepsy. A clinical study comparing immunotherapy in patients with autoantibodies or without an identified target antigen found neuroinflammatory features were predictive of a therapeutic response. New in-vitro and in-vivo studies, and spontaneous animal models, have confirmed the pathogenicity and epileptogenicity of neuronal antibodies and their relevance to other mammals. SUMMARY Neuronal antibodies are an important cause of autoimmune epileptic encephalopathy, early recognition is important as there may be an underlying tumour, and early treatment is associated with a better outcome. In the absence of an antibody, the clinician should adopt a pragmatic approach and consider a trial of immunotherapy when other causes have been excluded.
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Affiliation(s)
- Sukhvir Wright
- aDepartment of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK bNuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, Oxford, UK
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Ünverengil G, Vanli Yavuz EN, Tüzün E, Erdağ E, Kabadayi S, Bilgiç B, Baykan B. Brain Infiltration of Immune Cells in CASPR2-Antibody Associated Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis. Noro Psikiyatr Ars 2016; 53:344-347. [PMID: 28360810 DOI: 10.5152/npa.2016.15932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 02/26/2016] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Antibodies directed against neuronal surface antigens have recently been identified in patients with focal temporal lobe epilepsy (TLE) of unknown cause and mesial TLE with hippocampal sclerosis (MTLE-HS), thereby emphasizing the role of autoimmunity in TLE. Antibodies to contactin-associated protein-like 2 (CASPR2) are prevalent in MTLE-HS patients. We aimed to find out whether anti-neuronal autoimmunity might be involved in CASPR2 antibody-related MTLE-HS. METHODS Surgically resected medial temporal lobe specimens of seropositive and seronegative MTLE-HS patients were examined with hematoxylin and eosin and immunohistochemical staining using specific immune cell markers. RESULTS Two of 5 CASPR2 antibody-positive MTLE-HS patients showed polymorphonuclear and mononuclear cells infiltrating the subarachnoidal region. One of these patients also showed mononuclear cell infiltration in the parenchyma of the temporal lobe cortex. Subarachnoidal and parenchymal infiltrates contained CD3+, CD8+, and CD68+ cells. None of the 13 seronegative MTLE-HS patients displayed cellular infiltrates in their brain samples, and all MTLE-HS patients showed marked neuronal cell loss but no immune cell infiltration in their hippocampi. CONCLUSION Our results show that CASPR2 antibody-associated MTLE-HS can present with central nervous system inflammation; thus, this subtype of MTLE-HS might have an autoimmune origin.
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Affiliation(s)
- Gökçen Ünverengil
- Department of Pathology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Ebru Nur Vanli Yavuz
- Department of Neurology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Erdem Tüzün
- Department of Neurology, İstanbul University Institute of Experimental Medicine Research, İstanbul, Turkey
| | - Ece Erdağ
- Department of Neurology, İstanbul University Institute of Experimental Medicine Research, İstanbul, Turkey
| | - Sevil Kabadayi
- Department of Neurology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Bilge Bilgiç
- Department of Pathology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Betül Baykan
- Department of Neurology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Wright S, Geerts AT, Jol-van der Zijde CM, Jacobson L, Lang B, Waters P, van Tol MJD, Stroink H, Neuteboom RF, Brouwer OF, Vincent A. Neuronal antibodies in pediatric epilepsy: Clinical features and long-term outcomes of a historical cohort not treated with immunotherapy. Epilepsia 2016; 57:823-31. [PMID: 26996997 PMCID: PMC4864754 DOI: 10.1111/epi.13356] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In autoimmune encephalitis the etiologic role of neuronal cell-surface antibodies is clear; patients diagnosed and treated early have better outcomes. Neuronal antibodies have also been described in patients with pediatric epilepsy without encephalitis. The aim was to assess whether antibody presence had any effect on long-term outcomes in these patients. METHODS Patients (n = 178) were recruited between 1988 and 1992 as part of the prospective Dutch Study of Epilepsy in Childhood; none received immunotherapy. Healthy age-matched bone-marrow donors served as controls (n = 112). All sera were tested for serum N-methyl-d-aspartate receptor (NMDAR), alpha amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, leucine rich glioma inactivated 1, contactin associated protein like 2 (CASPR2), contactin-2, glutamic acid decarboxylase, and voltage gated potassium channel (VGKC)-complex antibodies by standard techniques. No cerebrospinal fluid (CSF) samples were available. Results were correlated with clinical data collected over 15 years. RESULTS Seventeen patients (9.5%) were positive for VGKC complex (n = 3), NMDAR (n = 7), CASPR2 (n = 4), and contactin-2 (n = 3), compared to three (3/112; 2.6%) healthy controls (VGKC complex [n = 1], NMDAR [n = 2]; p = 0.03; Fisher's exact test). Titers were relatively low (≤1:100 for cell-surface antibodies), but 8 (47%) of the 17 positive samples bound to the surface of live hippocampal neurons consistent with a potential pathogenic antibody. Preexisting cognitive impairment was more frequent in antibody-positive patients (9/17 vs. 33/161; p = 0.01). Fourteen antibody-positive patients were treated with standard antiepileptic drugs (AEDs); three (17%) became intractable but this was not different from the 16 (10%) of 161 antibody-negative patients. In 96 patients with available follow-up samples at 6 and/or 12 months, 6 of 7 positive antibodies had disappeared and, conversely, antibodies had appeared for the first time in a further 7 patients. SIGNIFICANCE Neuronal antibodies were found at low levels in 9.5% of patients with new-onset pediatric epilepsy but did not necessarily persist over time, and the development of antibodies de novo in later samples suggests they could be due to a secondary response to neuronal damage or inflammation. Moreover, as the response to standard AEDs and the long-term outcome did not differ from those of antibody-negative pediatric patients, these findings suggest that routine neuronal antibody testing is unlikely to be helpful in pediatric epilepsy. However, the higher incidence of preexisting cognitive problems in the antibody-positive group, the CASPR2 and contactin-2 antibodies in 7 of 17 patients, and the binding of 8 of 17 of serum samples to live hippocampal neurons suggest that neuronal antibodies, even if secondary, could contribute to the comorbidities of pediatric epilepsy.
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Affiliation(s)
- Sukhvir Wright
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Ada T Geerts
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
| | - Maarten J D van Tol
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Stroink
- Departments of Pediatric Neurology and Neurology, Canisius Hospital, Nijmegen, The Netherlands
| | - Rinze F Neuteboom
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe University Hospital, University of Oxford, Oxford, United Kingdom
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Albert DV, Pluto CP, Weber A, Vidaurre J, Barbar-Smiley F, Abdul Aziz R, Driest K, Bout-Tabaku S, Ruess L, Rusin JA, Morgan-Followell B. Utility of Neurodiagnostic Studies in the Diagnosis of Autoimmune Encephalitis in Children. Pediatr Neurol 2016; 55:37-45. [PMID: 26724889 DOI: 10.1016/j.pediatrneurol.2015.10.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 10/31/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Autoimmune encephalitis is currently a clinical diagnosis without widely accepted diagnostic criteria, often leading to a delay in diagnosis. The utility of magnetic resonance imaging (MRI) and electroencephalography (EEG) in this disease is unknown. The objective of this study was to identify disease-specific patterns of neurodiagnostic studies (MRI and EEG) for autoimmune encephalitis in children. METHODS We completed a retrospective chart review of encephalopathic patients seen at a large pediatric hospital over a four year interval. Clinical presentation, autoantibody status, and MRI and EEG findings were identified and compared. Individuals with autoantibodies were considered "definite" cases, whereas those without antibodies or those with only thyroperoxidase antibodies were characterized as "suspected." RESULTS Eighteen patients met the inclusion criteria and autoantibodies were identified in nine of these. The patients with definite autoimmune encephalitis had MRI abnormalities within limbic structures, most notably the anteromedial temporal lobes (56%). Only individuals with suspected disease had nontemporal lobe cortical lesions. Sixteen patients had an EEG and 13 (81%) of these were abnormal. The most common findings were abnormal background rhythm (63%), generalized slowing (50%), focal slowing (43%), and focal epileptiform discharges (31%). Sleep spindle abnormalities occurred in 38% of patients. There were no specific differences in the EEG findings between the definite and suspected cases. Focal EEG findings only correlated with a focal lesion on MRI in a single definite case. CONCLUSIONS Pediatric patients with definite autoimmune encephalitis have a narrow spectrum of MRI abnormalities. Conversely, EEG abnormalities are mostly nonspecific. All patients in our cohort had abnormalities on one or both of these neurodiagnostic studies.
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Affiliation(s)
- Dara V Albert
- Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; College of Medicine, The Ohio State University, Columbus, Ohio
| | - Charles P Pluto
- College of Medicine, The Ohio State University, Columbus, Ohio; Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Amanda Weber
- Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Jorge Vidaurre
- Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; College of Medicine, The Ohio State University, Columbus, Ohio
| | - Fatima Barbar-Smiley
- Section of Rheumatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Rabheh Abdul Aziz
- Section of Rheumatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kyla Driest
- College of Medicine, The Ohio State University, Columbus, Ohio; Section of Rheumatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Sharon Bout-Tabaku
- College of Medicine, The Ohio State University, Columbus, Ohio; Section of Rheumatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Lynne Ruess
- College of Medicine, The Ohio State University, Columbus, Ohio; Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jerome A Rusin
- College of Medicine, The Ohio State University, Columbus, Ohio; Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Bethanie Morgan-Followell
- Section of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; College of Medicine, The Ohio State University, Columbus, Ohio.
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27
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Neuronal autoantibodies in epilepsy patients with peri-ictal autonomic findings. J Neurol 2016; 263:455-66. [DOI: 10.1007/s00415-015-8002-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 12/12/2015] [Accepted: 12/16/2015] [Indexed: 12/30/2022]
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Abstract
This review reports the available evidence on the activation of the innate and adaptive branches of the immune system and the related inflammatory processes in epileptic disorders and the putative pathogenic role of inflammatory processes developing in the brain, as indicated by evidence from experimental and clinical research. Indeed, there is increasing knowledge supporting a role of specific inflammatory mediators and immune cells in the generation and recurrence of epileptic seizures, as well as in the associated neuropathology and comorbidities. Major challenges in this field remain: a better understanding of the key inflammatory pathogenic pathways activated in chronic epilepsy and during epileptogenesis, and how to counteract them efficiently without altering the homeostatic tissue repair function of inflammation. The relevance of this information for developing novel therapies will be highlighted.
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Affiliation(s)
- Annamaria Vezzani
- Department of Neuroscience, IRCSS-Istituto di Ricerche Farmacologiche "Mario Negri," 20156 Milano, Italy
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands Department of (Neuro)Pathology, Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands SEIN-Stichting Epilepsie Instellingen Nederland, Heemstede 2103 SW, The Netherlands
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Hacohen Y, Singh R, Rossi M, Lang B, Hemingway C, Lim M, Vincent A. Clinical relevance of voltage-gated potassium channel–complex antibodies in children. Neurology 2015; 85:967-75. [PMID: 26296514 DOI: 10.1212/wnl.0000000000001922] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To assess the clinical and immunologic findings in children with voltage-gated potassium channel (VGKC)-complex antibodies (Abs). METHODS Thirty-nine of 363 sera, referred from 2 pediatric centers from 2007 to 2013, had been reported positive (.100 pM) for VGKC-complex Abs. Medical records were reviewed retrospectively and the patients’ condition was independently classified as inflammatory (n 5 159) or noninflammatory (n 5 204). Positive sera (.100 pM) were tested/retested for the VGKC complex Ab–positive complex proteins LGI1 and CASPR2, screened for binding to live hippocampal neurons, and 12 high-titer sera (.400 pM) tested by radioimmunoassay for binding to VGKC Kv1 subunits with or without intracellular postsynaptic density proteins. RESULTS VGKC-complex Abs were found in 39 children, including 20% of encephalopathies and 7.6% of other conditions (p 5 0.001). Thirty children had inflammatory conditions and 9 had noninflammatory etiologies but titers.400 pM (n512) were found only in inflammatory diseases (p , 0.0001). Four sera, including from 2 children with coexisting NMDA receptor Abs and one with Guillain-Barré syndrome and Abs to both LGI1 and CASPR2, bound to hippocampal neurons. None of the sera bound detectably to VGKC Kv1 subunits on live HEK cells, but 4 of 12 .400 pM sera immunoprecipitated VGKC Kv1 subunits, with or without postsynaptic densities, extracted from transfected cells. CONCLUSION Positive VGKC-complex Abs cannot be taken to indicate a specific clinical syndrome in children, but appear to be a nonspecific biomarker of inflammatory neurologic diseases, particularly of encephalopathy. Some of the Abs may bind to intracellular epitopes on the VGKC subunits, or to the intracellular interacting proteins, but in many the targets remain undefined.
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Abstract
Despite the fact that epilepsy is the third most common chronic brain disorder, relatively little is known about the processes leading to the generation of seizures. Accumulating data support an autoimmune basis in patients with antiepileptic drug-resistant seizures. Besides, recent studies show that epilepsy and autoimmune disease frequently co-occur. Autoimmune epilepsy is increasingly recognized in the spectrum of neurological disorders characterized by detection of neural autoantibodies in serum or spinal fluid and responsiveness to immunotherapy. An autoimmune cause is suspected based on frequent or medically intractable seizures and the presence of at least one neural antibody, inflammatory changes indicated in serum or spinal fluid or on MRI, or a personal or family history of autoimmunity. It is essential that an autoimmune etiology be considered in the initial differential diagnosis of new onset epilepsy, because early immunotherapy assures an optimal outcome for the patient.
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Nosadini M, Mohammad SS, Ramanathan S, Brilot F, Dale RC. Immune therapy in autoimmune encephalitis: a systematic review. Expert Rev Neurother 2015; 15:1391-419. [DOI: 10.1586/14737175.2015.1115720] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Wright S, Hashemi K, Stasiak L, Bartram J, Lang B, Vincent A, Upton AL. Epileptogenic effects of NMDAR antibodies in a passive transfer mouse model. Brain 2015; 138:3159-67. [PMID: 26373601 DOI: 10.1093/brain/awv257] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/21/2015] [Indexed: 12/20/2022] Open
Abstract
Most patients with N-methyl D-aspartate-receptor antibody encephalitis develop seizures but the epileptogenicity of the antibodies has not been investigated in vivo. Wireless electroencephalogram transmitters were implanted into 23 C57BL/6 mice before left lateral ventricle injection of antibody-positive (test) or healthy (control) immunoglobulin G. Mice were challenged 48 h later with a subthreshold dose (40 mg/kg) of the chemo-convulsant pentylenetetrazol and events recorded over 1 h. Seizures were assessed by video observation of each animal and the electroencephalogram by an automated seizure detection programme. No spontaneous seizures were seen with the antibody injections. However, after the pro-convulsant, the test mice (n = 9) had increased numbers of observed convulsive seizures (P = 0.004), a higher total seizure score (P = 0.003), and a higher number of epileptic 'spike' events (P = 0.023) than the control mice (n = 6). At post-mortem, surprisingly, the total number of N-methyl D-aspartate receptors did not differ between test and control mice, but in test mice the levels of immunoglobulin G bound to the left hippocampus were higher (P < 0.0001) and the level of bound immunoglobulin G correlated with the seizure scores (R(2) = 0.8, P = 0.04, n = 5). Our findings demonstrate the epileptogenicity of N-methyl D-aspartate receptor antibodies in vivo, and suggest that binding of immunoglobulin G either reduced synaptic localization of N-methyl D-aspartate receptors, or had a direct effect on receptor function, which could be responsible for seizure susceptibility in this acute short-term model.
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Affiliation(s)
- Sukhvir Wright
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Kevan Hashemi
- 2 Open Source Instruments Inc, 130 Mount Auburn Street, Watertown, MA 02472, USA
| | - Lukasz Stasiak
- 3 Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, OX1 3PT, UK
| | - Julian Bartram
- 3 Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, OX1 3PT, UK
| | - Bethan Lang
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Angela Vincent
- 1 Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - A Louise Upton
- 3 Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, OX1 3PT, UK
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Sinmaz N, Amatoury M, Merheb V, Ramanathan S, Dale RC, Brilot F. Autoantibodies in movement and psychiatric disorders: updated concepts in detection methods, pathogenicity, and CNS entry. Ann N Y Acad Sci 2015; 1351:22-38. [DOI: 10.1111/nyas.12764] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nese Sinmaz
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Mazen Amatoury
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Vera Merheb
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
| | - Russell C. Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research; Kids Research Institute at The Children's Hospital at Westmead, University of Sydney; Sydney Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School, University of Sydney; Sydney Australia
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Bello-Espinosa LE, Rajapakse T, Rho JM, Buchhalter J. Efficacy of intravenous immunoglobulin in a cohort of children with drug-resistant epilepsy. Pediatr Neurol 2015; 52:509-16. [PMID: 25882078 DOI: 10.1016/j.pediatrneurol.2014.11.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/15/2014] [Accepted: 11/18/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We describe the experience of a pediatric epilepsy center regarding the efficacy of intravenous immunoglobulin for drug-resistant seizures in children. METHODS A retrospective chart review of all children in a community-based, children's hospital neurology clinic from 2006 to 2012, inclusive, with intractable epilepsy who were treated with intravenous immunoglobulin for a minimum of six cycles was performed. Data collected included patient demographics, seizure and epilepsy syndrome type, presumed etiology for the seizures, and seizure frequency. Response to intravenous immunoglobulin was defined as "positive" if either seizure freedom or ≥50% reduction of seizures was achieved. RESULTS Twenty-seven children (3-17 years old) were identified and included in the analysis. Following treatment with intravenous immunoglobulin, the following outcomes were noted: four were seizure-free, eight had 90% reduction, five had 75% reduction, and five had 50% reduction. A total of 22 (81%) patients had a positive clinical response to treatment from baseline. Five patients (19%) were not responsive. No clear relationship of responsiveness to intravenous immunoglobulin with regard to age, gender, or epilepsy syndrome was apparent; however, the small numbers in each category precluded meaningful statistical analysis. SIGNIFICANCE Our findings and those of others suggest that intravenous immunoglobulin is a potentially high efficacy, low side effect profile therapy in the treatment of children with drug-resistant epilepsies. Intravenous immunoglobulin was able to reduce multiple seizure types in a variety of epilepsy etiologies, including those of unknown cause.
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Affiliation(s)
- Luis E Bello-Espinosa
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Thilinie Rajapakse
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jong M Rho
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada.
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Suleiman J, Dale RC. The recognition and treatment of autoimmune epilepsy in children. Dev Med Child Neurol 2015; 57:431-40. [PMID: 25483277 DOI: 10.1111/dmcn.12647] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 01/07/2023]
Abstract
There is emerging interest in autoimmune epilepsy, which represents a small but potentially treatable form of epilepsy. Most insights into autoimmune epilepsy derive from the recent descriptions of autoimmune encephalitis that takes two general forms: a focal encephalitis (such as limbic) or a diffuse encephalitis (such as anti-N-methyl-D-aspartate receptor [NMDAR] encephalitis). The features of autoimmune epilepsy include acute or subacute onset of seizures, usually in the context of encephalopathy, and inflammation of the central nervous system on testing cerebrospinal fluid or magnetic resonance imaging. Neuronal antibodies associated with autoimmune encephalitis and seizures in children include NMDAR, voltage-gated potassium channel complex, glycine receptor, γ-Aminobutyric acid type A receptor (GABA(A)R), γ-Aminobutyric acid type B receptor (GABA(B)R), and glutamic acid decarboxylase antibodies. These antibodies support the diagnosis of autoimmune epilepsy, but are not essential for diagnosis. When autoimmune epilepsy is suspected, first-line immune therapy with corticosteroids in addition to intravenous immunoglobulin or plasma exchange should be considered. Second-line therapy with rituximab or cyclophosphamide can be considered if the syndrome is severe. A response to immune therapy supports the diagnosis of autoimmune epilepsy. Neuronal antibodies are increasingly found in patients with focal epilepsy of unknown cause who do not have 'encephalitis'. Recent epidemiological studies support the link between epilepsy and autoimmune diseases. Future studies need to define the spectrum of autoimmune epilepsy and focus on early identification and treatment.
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Affiliation(s)
- Jehan Suleiman
- Department of Paediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; Paediatrics and Child Health Discipline, Clinical School, The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Ramberger M, Peschl P, Schanda K, Irschick R, Höftberger R, Deisenhammer F, Rostásy K, Berger T, Dalmau J, Reindl M. Comparison of diagnostic accuracy of microscopy and flow cytometry in evaluating N-methyl-D-aspartate receptor antibodies in serum using a live cell-based assay. PLoS One 2015; 10:e0122037. [PMID: 25815887 PMCID: PMC4376531 DOI: 10.1371/journal.pone.0122037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 02/06/2015] [Indexed: 01/17/2023] Open
Abstract
N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune neurological disease, diagnosed by a specific autoantibody against NMDAR. Antibody testing using commercially available cell-based assays (CBA) or immunohistochemistry on rat brain tissue has proven high specificity and sensitivity. Here we compare an immunofluorescence live CBA to a flow cytometry (FACS) based assay to detect NMDAR antibodies by their binding to the surface of HEK293A cells functionally expressing NMDAR. Both assays were first established using a discovery group of 76 individuals and then validated in a group of 32 patients in a blinded manner. In the CBA, 23 of 23 patients with NMDAR encephalitis were positive for NMDAR antibodies and 0 of 85 controls (32 healthy controls and 53 patients with other neurological diseases), resulting in a sensitivity and specificity of 100% (95% confidence intervals (CI) 85.1-100.0 and 95.7-100.0, respectively). The FACS based assay detected NMDAR antibodies in 20 of 23 patients and in 0 of 85 controls. Therefore, with an equally high specificity (95% CI 95.7-100.0) the sensitivity of the FACS based assay was 87% (95% CI 66.4-97.2). Comparing antibody titers from CBA with delta median fluorescence intensities from FACS showed a high concordance (kappa = 0.943, p<0.0001) and correlation (r = 0.697, p<0.0001). In conclusion, evaluation of the FACS based assay revealed a lower sensitivity and high inter-assay variation, making the CBA a more reliable detection method.
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Affiliation(s)
- Melanie Ramberger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Peschl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Regina Irschick
- Division of Neuroanatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Florian Deisenhammer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Rostásy
- Pediatric Neurology, Witten/Herdecke University, Children’s Hospital Datteln, Datteln, Germany
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Josep Dalmau
- Institució Catalana de Recerca i Estudis Avançats (ICREA), IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- * E-mail:
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Fukuyama T, Takahashi Y, Kubota Y, Mogami Y, Imai K, Kondo Y, Sakuma H, Tominaga K, Oguni H, Nishimura S. Semi-quantitative analyses of antibodies to N-methyl-d-aspartate type glutamate receptor subunits (GluN2B & GluN1) in the clinical course of Rasmussen syndrome. Epilepsy Res 2015; 113:34-43. [PMID: 25986190 DOI: 10.1016/j.eplepsyres.2015.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/02/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In Rasmussen syndrome (RS), in addition to the predominant involvement of cytotoxic T cells, heterogeneous autoantibodies against neural molecules are also found, but their function has not been elucidated. We examined antibodies to N-methyl-d-aspartate (NMDA) type glutamate receptor (GluR) subunits (GluN2B & GluN1) semi-quantitatively in cerebrospinal fluid (CSF) samples from RS patients, and evaluated their changes over time and their roles in immunopathogenesis. METHODS Autoantibodies against N-terminal and C-terminal of GluN2B and GluN1 were examined in 40 CSF samples collected from 18 RS patients 5 to 180 months after the onset of RS. Epileptic patients without infectious etiology or progressive clinical course served as disease controls (n=23). Synthesized peptides encoding the extracellular and intracellular domains of human GluN2B and GluN1 subunits were used as antigens in ELISA. We defined the cut-off for these antibodies as mean +2 standard deviations (optimal density) of the disease controls. MRI were evaluated according to the MRI staging proposed by Bien et al. (2002b, Neurology 58, 250). RESULTS CSF levels of antibodies against N-terminal and C-terminal of GluN2B were higher in RS patients than in disease controls (p<0.01). Likewise, CSF levels of antibodies against N-terminal and C-terminal of GluN1 were also higher in RS patients than in disease controls (p<0.01). All four antibodies tested were below cut-off levels in almost all CSF samples collected within one year from epilepsy onset. The proportions of CSF samples with these antibodies above cut-off levels were highest from 12 to 23 months after epilepsy onset, and declined after 24 months. CSF levels of these antibodies were higher when seizure occurred daily than when seizure occurred less frequently (p<0.01), and were higher at MRI stage 3 than at MRI stages 0, 2 and 4 (p<0.05), except for anti-GluN1-CT antibody at stage 2. CONCLUSIONS Broad epitope recognition spectrum and delayed production of autoantibodies to NMDA type GluR in CSF of RS patients suggest that the autoantibodies are produced against NMDA type GluR antigens derived from cytotoxic T cell-mediated neuronal damages. These antibodies may impact the pathophysiology of RS in the most active stage, and could be a marker for active inflammation in the clinical course of RS. Further studies including passive transfer of the antibodies to mice may reveal the pivotal roles of the antibodies in RS.
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Affiliation(s)
- Tetsuhiro Fukuyama
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan.
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan; Department of Pediatrics, Gifu University School of Medicine, Yanagido, Gifu, Japan; School of Pharmaceutical Sciences, University Shizuoka, Shizuoka, Japan
| | - Yuko Kubota
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Yukiko Mogami
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Katsumi Imai
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Yoshiyuki Kondo
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Hiroshi Sakuma
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Koji Tominaga
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirokazu Oguni
- Department of Pediatrics, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shigeko Nishimura
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
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Kim SY, Choi SA, Ryu HW, Kim H, Lim BC, Hwang H, Chae JH, Choi J, Kim KJ, Hwang YS, Lee ST, Chu K, Lee SK. Screening Autoimmune Anti-neuronal Antibodies in Pediatric Patients with Suspected Autoimmune Encephalitis. J Epilepsy Res 2014; 4:55-61. [PMID: 25625089 PMCID: PMC4295054 DOI: 10.14581/jer.14012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/01/2014] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: The aim of this study was to identify and describe the pediatric autoimmune encephalitis cases positive for anti-neuronal antibody tests. Methods: Screening of six anti-neuronal antibodies in 23 children with suspected autoimmune encephalitis was performed by cell-based indirect immunofluorescence test with patients’ serum or cerebrospinal fluid. Results: Among the 23 cases enrolled here, eight patients (35%) were positive for the anti-N-methyl-d-aspartate (NMDA) receptor antibody and one patient (4%) was positive for the anti-contactin-associated protein-like 2 (CASPR2) antibody. In the anti-NMDA receptor antibody-positive group, seizure and movement disorders were the most prominent features and were present in all patients. A tumor was present in only one patient. Three patients with infant- and toddler-onset disease did not exhibit a classic multistage illness. In addition to seizure and dyskinesia, aphasia or mutism without severe consciousness impairment was present in all three patients. These atypical clinical presentations may suggest different pathomechanism of anti-NMDA receptor encephalitis among these age groups. The patient who was positive for the anti-CASPR2 antibody was an 8-year-old girl who presented with fever, encephalopathy, and seizure. Neuromyotonia or other dyskinesia was not present. Conclusions: Eight anti-NMDA receptor antibody positive patients and one CASPR2 positive patient were identified from the screening of six anti-neuronal antibodies in pediatric patients suspected with autoimmune encephalitis. Developmental regression specifically for language skills was suggested as one of the atypical clinical features in infants and toddler onset anti-NMDA receptor antibody positive patients.
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Affiliation(s)
- Soo Yeon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Sun Ah Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Hye Won Ryu
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Hunmin Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Hee Hwang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Jong-Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Jieun Choi
- Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Yong Seung Hwang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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Abstract
Status epilepticus (SE) describes persistent or recurring seizures without a return to baseline mental status and is a common neurologic emergency. SE can occur in the context of epilepsy or may be symptomatic of a wide range of underlying etiologies. The clinician's aim is to rapidly institute care that simultaneously stabilizes the patient medically, identifies and manages any precipitant conditions, and terminates seizures. Seizure management involves "emergent" treatment with benzodiazepines followed by "urgent" therapy with other antiseizure medications. If seizures persist, then refractory SE is diagnosed and management options include additional antiseizure medications or infusions of midazolam or pentobarbital. This article reviews the management of pediatric SE and refractory SE.
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Wuerfel E, Bien CG, Vincent A, Woodhall M, Brockmann K. Glycine receptor antibodies in a boy with focal epilepsy and episodic behavioral disorder. J Neurol Sci 2014; 343:180-2. [PMID: 24880541 DOI: 10.1016/j.jns.2014.05.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 04/09/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
A wide range of clinical presentations including neuromuscular disorders and autoimmune encephalopathies is being recognized to be associated with various autoantibodies. Glycine receptor (GlyR) antibodies have so far been found mainly in adult patients with phenotypes comprising progressive encephalomyelitis with rigidity and myoclonus or stiff-person syndrome. We report a four-year-old boy who presented with a two-year-history of drug-resistant focal epilepsy with unusual seizure semiology, temper tantrums, headache, clumsiness, and intermittently impaired speech. While MRI and CSF were normal, screening for autoimmune antibodies revealed GlyR antibodies in serum. Immunomodulatory treatment with steroids resulted in rapid and complete resolution of symptoms. Our observation widens the spectrum of clinical presentations associated with GlyR antibodies and emphasizes the potential relevance of neuronal autoantibodies in epilepsies of unknown cause in children as well as in adults.
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Affiliation(s)
- Eva Wuerfel
- Interdisciplinary Pediatric Center for Children with Developmental Disabilities and Severe Chronic Disorders, University Medical Center, Georg August University Göttingen, Robert Koch Str. 40, 37075 Göttingen, Germany.
| | | | - Angela Vincent
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Mark Woodhall
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Knut Brockmann
- Interdisciplinary Pediatric Center for Children with Developmental Disabilities and Severe Chronic Disorders, University Medical Center, Georg August University Göttingen, Robert Koch Str. 40, 37075 Göttingen, Germany
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