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Hasan SF, Lutfi L, Shukur M, Alemam S, Esmaeel H, Nawaz F. Psychiatric Manifestations in an Adolescent With Voltage-Gated Potassium Channels (VGKC) Autoimmune Encephalitis: A Case Report. Cureus 2023; 15:e39960. [PMID: 37416039 PMCID: PMC10320328 DOI: 10.7759/cureus.39960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 07/08/2023] Open
Abstract
Autoimmune encephalitis (AE) is a newly defined group of disorders characterized by psychiatric symptoms such as psychosis and manic or hypomanic symptoms, with or without neurological symptoms. The most common neurological symptoms include seizures, altered mental status, autonomic disability, disorientation, and movement disorders. Our case report describes a type of AE caused by circulating autoantibodies against voltage-gated potassium channels (VGKC), which has not been reported before in the United Arab Emirates. This case report describes the psychiatric manifestations in a 17-year-old female with AE. It aims to shed light on the rare presentations of AE, discuss the various causes and management in greater depth, and the importance of suspecting and diagnosing AE early in the illness course. This rare case highlights the need for further research on the underlying biological, psychological, and social risk factors for developing AE in this region, and to direct further attention to developing early-intervention strategies in the vulnerable patient population.
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Affiliation(s)
- Safa F Hasan
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
| | - Lubna Lutfi
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
| | - Mahmood Shukur
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
| | - Shokry Alemam
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
| | - Hanan Esmaeel
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
| | - Faisal Nawaz
- Department of Psychiatry, Al Amal Psychiatric Hospital, Dubai, ARE
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2
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Cho JH, Kim SJ, Park KW. Anti-LGI1 Encephalitis Presented With Prominent Psychosis Without Loss of Consciousness. Dement Neurocogn Disord 2023; 22:78-80. [PMID: 37179694 PMCID: PMC10166675 DOI: 10.12779/dnd.2023.22.2.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Ja Hyeon Cho
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Sun Jung Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Kyung Won Park
- Department of Neurology, Dong-A University Hospital, Busan, Korea
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
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3
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Klemencic Kozul T, Yudina A, Donovan C, Pinto A, Osman C. Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions. BMC Health Serv Res 2022; 22:904. [PMID: 35831856 PMCID: PMC9277970 DOI: 10.1186/s12913-022-08210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Plasma exchange (PLEX) is an effective treatment for antibody-mediated neurological disorders and has been shown to be equally efficacious to intravenous immunoglobulin (IVIg) with comparable adverse event profiles. IVIg has traditionally been the preferred treatment option due to its ease of use. However, advancing technology has allowed PLEX to be performed with a centrifugal system via peripheral access as opposed to central access via a membrane filter. Methods We prospectively collected data from a cohort of patients who underwent PLEX at the Wessex Neurological Centre, UK, to perform a cost-minimisation analysis comparing PLEX to IVIg, the standard of care, between May 2019 and May 2020. Data obtained included indication, admission type (inpatient, daycase or intensive care), access (peripheral or central), number of PLEX cycles, exchange volume, patient weight, complications and clinical outcomes. The cost of PLEX delivered in an outpatient setting for an average 80kg person was calculated and compared to the equivalent cost of delivering IVIg by means of a cost-minimization model. Results The provision of PLEX was roughly half as costly when compared to what it would have been for IVIg (£886 per exchange vs £1778 per infusion or £4432 per cycle of 5 exchanges vs £8890 per cycle of 5 infusions). Our cohort included a total of 44 patients who received a total of 357 PLEX exchanges during the 12-month period (the majority of which were in a daycase setting). We calculated an annual cost saving for PLEX over IVIg of £318,589. The robustness of this result was confirmed by a one-way deterministic sensitivity analysis, showing the cost-effectiveness of PLEX. Conclusion Our findings demonstrate that PLEX is more cost-effective than IVIg in this setting. Our study supports the economic case for development of plasma exchange centres in regional neurology units, a case made all the more relevant in the context of constrained supplies of IVIg. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08210-z.
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Affiliation(s)
| | - Anna Yudina
- Terumo Blood and Cell Technologies Europe, Zaventem, Belgium
| | - Carley Donovan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ashwin Pinto
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chinar Osman
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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4
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Miljkovic SS, Koenig BW. Altered Mental Status in the Emergency Department - When to Consider Anti-LGI-1 Encephalitis: Case Report. Clin Pract Cases Emerg Med 2021; 5:303-306. [PMID: 34437034 PMCID: PMC8373185 DOI: 10.5811/cpcem.2021.4.51535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/01/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Anti-leucine-rich glioma inactivated-1 (LGI-1) is one of few antibodies implicated in limbic encephalitis, a syndrome that can result in permanent neurological symptoms if left untreated. Case Report We present a patient with dystonic seizures, progressive cognitive decline, psychiatric symptoms and short-term memory loss, and mild hyponatremia diagnosed with anti-LGI-1 antibody limbic encephalitis. Conclusion There are few reports in the emergency medicine community describing anti-LGI-1 antibody limbic encephalitis. Delay in diagnosis can risk irreversible limbic damage. Therefore, it is important for the emergency physician to be aware of anti-LGI-1 antibody limbic encephalitis when presented with adult-onset seizures and altered mental status of unknown etiology.
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Affiliation(s)
- Stephanie S Miljkovic
- Creighton University School of Medicine, Department of Emergency Medicine, Phoenix, Arizona
| | - B Witkind Koenig
- Creighton University School of Medicine, Department of Emergency Medicine, Phoenix, Arizona
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5
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Smith KM, Dubey D, Liebo GB, Flanagan EP, Britton JW. Clinical Course and Features of Seizures Associated With LGI1-Antibody Encephalitis. Neurology 2021; 97:e1141-e1149. [PMID: 34233939 DOI: 10.1212/wnl.0000000000012465] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/18/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine risk factors associated with clinical relapses and development of chronic epilepsy in patients with anti-leucine-rich glioma-inactivated 1 (LGI1) IgG encephalitis. METHODS Patients with seizures related to LGI1-antibody encephalitis with ≥ 24 months of follow-up from disease onset were identified in the Mayo Clinic electronic medical record and Neuroimmunology lab records. Charts were reviewed to determine clinical factors, seizure types, imaging, treatment, occurrence of relapse, and outcome. Binary logistic regression analysis was performed to identify predictors of the development of chronic epilepsy. Univariate Cox proportional hazards regression was used to examine the influence of baseline characteristics on relapse risk. RESULTS Forty-nine patients with LGI1-antibody encephalitis and acute symptomatic seizures were identified. Almost all patients (n=48, 98%) were treated with immunotherapy. Eight had definite, and two had possible chronic epilepsy at last follow-up (10/49, 20.4%). Female sex (P=0.048) and younger age at disease onset (P=0.02) were associated with development of chronic epilepsy. Relapses occurred in 20 (40.8%), with a median time to first relapse of 7.5 months (range 3-94 months). Initial treatment with chronic steroid sparing immunotherapy was associated with reduced risk of relapse (hazards ratio=0.28, 95% CI 0.11-0.73, P=0.009). CONCLUSIONS Chronic epilepsy occurred in 20.4% of our patients with LGI1-antibody encephalitis despite aggressive immunotherapy. Risk factors for chronic epilepsy were female sex and earlier age of onset. Relapses occurred in 40.8% of patients with prolonged follow-up, and chronic steroid sparing immunotherapy was associated with a lower relapse rate.
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Affiliation(s)
| | | | - Greta B Liebo
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Rochester, MN
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Ismail II, Alnaser F, Al-Hashel JY. Seronegative limbic encephalitis manifesting as subacute amnestic syndrome: a case report and review of the literature. J Med Case Rep 2021; 15:130. [PMID: 33757596 PMCID: PMC7989010 DOI: 10.1186/s13256-021-02742-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background Limbic encephalitis (LE), a variant of autoimmune encephalitis, is inflammation of the limbic system of the brain. The disorder presents with subacute impairment of short-term memory, psychiatric manifestations, confusion and seizures. “Seronegative LE” is a challenging diagnosis in the absence of well-characterized autoantibodies. Case presentation A 33-year-old Kuwaiti woman with no relevant past history presented with subacute progressive amnesia of 6-month duration. Magnetic resonance imaging (MRI) showed bilateral hyperintensity of the limbic structures. An extensive workup of the blood and cerebrospinal fluid (CSF) failed to identify paraneoplastic or autoimmune antibodies. The diagnosis of seronegative LE was made, and immunotherapy was initiated, with improvement in cognitive function. Conclusion Seronegative LE is a challenging diagnosis. Inability to detect autoantibodies, especially early in the disease course, should not rule out the diagnosis of autoimmune encephalitis. Early diagnosis and treatment with immunotherapy may prevent irreversible brain damage.
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Affiliation(s)
| | - Fahad Alnaser
- Department of Radiology, Ibn Sina Hospital, Sabah Medical Region, Kuwait
| | - Jasem Y Al-Hashel
- Department of Neurology, Ibn Sina Hospital, Sabah Medical Region, Kuwait.,Health Sciences Centre, Department of Medicine, Kuwait University, Jabriya, Kuwait
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7
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Seizures in steroid-responsive encephalopathy. Neurol Sci 2020; 42:521-530. [PMID: 33219869 DOI: 10.1007/s10072-020-04891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
Steroid-responsive encephalopathy is a general term for diseases that are characterized by diffuse brain injury and respond well to corticosteroids or immunosuppressive agents, including Hashimoto's encephalopathy (HE), limbic encephalitis (LE), systemic lupus erythematosus encephalopathy (SLEE), antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitis encephalopathy (AASV), viral encephalitis (VE), and primary central nervous system lymphoma (PCNSL). Epilepsy and status epilepticus are the main manifestations of steroid-responsive encephalopathy. The spectrum of "autoimmune epilepsy" diseases, which has been approved by the epilepsy diagnostic recommendations of the International Antiepileptic League, is characterized by a high prevalence of epilepsy in central nervous system (CNS) autoimmune diseases and a variety of neuron-specific autoantibodies. Steroid-responsive encephalopathy with different causes may have different pathogeneses and has been suggested to be associated with some internal commonality producing seizure as the main symptom. Determining the regularity of seizures caused by steroid-responsive encephalopathy and implementing appropriate measures will help us improve the prognosis of patients. This paper summarizes the epidemiology, seizure onset, seizure type, and other characteristics of seizures in steroid-responsive encephalopathy (including HE, LE, SLEE, ANCA-associated systemic vasculitis encephalopathy, VE, and PCNSL) and then discusses the use of antiepileptic drugs to treat steroid-responsive encephalopathy.
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8
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 747] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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9
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Das J, Chauhan VD, Mills D, Johal NJ, Tan M, Matthews R, Keh R, Lilleker JB, Gosal D, Sharaf N. Therapeutic plasma exchange in neurological disorders: Experience from a tertiary neuroscience centre. Transfus Apher Sci 2019; 58:102654. [PMID: 31648858 DOI: 10.1016/j.transci.2019.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/13/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
Therapeutic plasma exchange (TPE) involves the extracorporeal separation of plasma from the cellular components of blood with replacement fluid, such as human albumin or fresh frozen plasma. A number of studies across the world revealed that more than one third of TPE procedures were performed for neurological disorders. Myasthenia gravis (MG), Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) were the most frequently cited indications for TPE, followed by multiple sclerosis (MS). However, treatments of these conditions have evolved over the years and it is likely that this has impacted on clinical practice. Here we present our experience of using TPE to treat neurological disorders. We reviewed the medical records of all 63 patients who received 349 procedures over 70 therapeutic cycles between 2012 and 2015 in a tertiary neurology centre. In total only 2 patients with GBS and MG were treated with TPE. The commonest indication was voltage gated potassium channel (VGKC) complex antibody associated disorders followed by CIDP and MS. There were 11 patients with limbic encephalitis. Nine of them had antibodies against VGKC complex and two had N-methyl-D-aspartate (NMDA) receptor antibodies. Sixty four percent of patients with limbic encephalitis and overall 78% of patients responded to TPE. The complication rate associated with this procedure was 8.6 per 100 therapeutic cycle. There was no treatment related mortality. We observed a change in indications of TPE compared to historical studies. It was less frequently used to treated GBS and MG. It was found to be safe and effective.
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Affiliation(s)
- Joyutpal Das
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
| | - Vanisha D Chauhan
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
| | - Daniel Mills
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Nicholas J Johal
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Maevis Tan
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Rachael Matthews
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Ryan Keh
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - James B Lilleker
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK; Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, M13 9PT, UK
| | - David Gosal
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Nazar Sharaf
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
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Loane C, Argyropoulos GPD, Roca-Fernández A, Lage C, Sheerin F, Ahmed S, Zamboni G, Mackay C, Irani SR, Butler CR. Hippocampal network abnormalities explain amnesia after VGKCC-Ab related autoimmune limbic encephalitis. J Neurol Neurosurg Psychiatry 2019; 90:965-974. [PMID: 31072956 PMCID: PMC6820158 DOI: 10.1136/jnnp-2018-320168] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Limbic encephalitis associated with antibodies to components of the voltage-gated potassium channel complex (VGKCC-Ab-LE) often leads to hippocampal atrophy and persistent memory impairment. Its long-term impact on regions beyond the hippocampus, and the relationship between brain damage and cognitive outcome, are poorly understood. We investigated the nature of structural and functional brain abnormalities following VGKCC-Ab-LE and its role in residual memory impairment. METHOD A cross-sectional group study was conducted. Twenty-four VGKCC-Ab-LE patients (20 male, 4 female; mean (SD) age 63.86 (11.31) years) were recruited post-acutely along with age- and sex-matched healthy controls for neuropsychological assessment, structural MRI and resting-state functional MRI (rs-fMRI). Structural abnormalities were determined using volumetry and voxel-based morphometry; rs-fMRI data were analysed to investigate hippocampal functional connectivity (FC). Associations of memory performance with neuroimaging measures were examined. RESULTS Patients showed selective memory impairment. Structural analyses revealed focal hippocampal atrophy within the medial temporal lobes, correlative atrophy in the mediodorsal thalamus, and additional volume reduction in the posteromedial cortex. There was no association between regional volumes and memory performance. Instead, patients demonstrated reduced posteromedial cortico-hippocampal and inter-hippocampal FC, which correlated with memory scores (r = 0.553; r = 0.582, respectively). The latter declined as a function of time since the acute illness (r = -0.531). CONCLUSION VGKCC-Ab-LE results in persistent isolated memory impairment. Patients have hippocampal atrophy with further reduced mediodorsal thalamic and posteromedial cortical volumes. Crucially, reduced FC of remaining hippocampal tissue correlates more closely with memory function than does regional atrophy.
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Affiliation(s)
- Clare Loane
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Institute of Cognitive Neuroscience, University College London Medical School, London, UK
| | | | | | - Carmen Lage
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Unidad de Deterioro Cognitivo, Servicio de Neurología, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Fintan Sheerin
- Department of Neuroradiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Samrah Ahmed
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Giovanna Zamboni
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Clare Mackay
- Oxford Centre for Human Brain Activity, University of Oxford, Oxford, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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11
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Osman C, Jennings R, El-Ghariani K, Pinto A. Plasma exchange in neurological disease. Pract Neurol 2019; 20:92-99. [PMID: 31300488 DOI: 10.1136/practneurol-2019-002336] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 01/08/2023]
Abstract
Plasma exchange is a highly efficient technique to remove circulating autoantibodies and other humoral factors rapidly from the vascular compartment. It was the first effective acute treatment for peripheral disorders such as Guillain-Barré syndrome and myasthenia gravis before intravenous immunoglobulin became available. The recent recognition of rapidly progressive severe antibody-mediated central nervous system disorders, such as neuromyelitis optica spectrum disorders and anti-N-methyl-D-aspartate-receptor encephalitis, has renewed interest in using plasma exchange for their acute treatment also. In this review we explain the principles and technical aspects of plasma exchange, review its current indications, and discuss the implications for its provision in the UK.
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Affiliation(s)
- Chinar Osman
- Neurosciences, Wessex Neurological Centre, Southampton, UK
| | | | - Khaled El-Ghariani
- Therapeutics and Tissue Services, NHS Blood and Transplant, Sheffield Teaching Hospitals NHS Trust and the University of Sheffield, Sheffield, UK
| | - Ashwin Pinto
- Neurosciences, Wessex Neurological Centre, Southampton, UK
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12
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Pham HP, Staley EM, Schwartz J. Therapeutic plasma exchange – A brief review of indications, urgency, schedule, and technical aspects. Transfus Apher Sci 2019; 58:237-246. [DOI: 10.1016/j.transci.2019.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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13
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Chandra SR, Ray S, Isaac T, R Pai A, Krishnareddy H, Dhar D, Philip M. A clinical TRIAD for early suspicion of autoimmune encephalitis as a possibility in patients presenting with progressive cognitive decline. Asian J Psychiatr 2019; 41:5-12. [PMID: 30836326 DOI: 10.1016/j.ajp.2019.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/27/2018] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
Abstract
Patients with progressive cognitive decline mostly suffer from degenerative disease and carry a relatively poor prognosis. But small groups among these patients have a potentially treatable cause of illness and therefore every patient with dementia needs to be considered treatable unless proved otherwise. This group can be identified only by high degree of suspicion based on clinical clues. We have evaluated the validity of some simple clinical clues which we noticed in our patients with immune mediated dementias. The Panic score, Epsworth sleepiness score, catatonic symptoms and history of seizures were compared between 23 and 11 patients with serologically confirmed anti-NMDA antibody and anti-VGKC antibody associated encephalitis respectively. They were compared with 20 patients with probable behavioral variant of Frontotemporal dementia (bvFTD) and 20 patients with probable Alzheimer's disease (AD). Chi-square test was used to compare across the groups and there was significant difference (P < 0.05) across the 4 groups comprising anti NMDA encephalitis, anti VGKC encephalitis, FTD and AD among the four variables (Panic scores, Catatonic symptoms, Epsworth sleepiness score and seizures) studied. Our study revealed that panic and sleepiness is highly significant when tested across all groups and catatonia showed a trend towards NMDA and when compared with degenerative dementia versus immune mediated syndromes all the 4 parameters were highly significant This simple bedside TRIAD of panic, sleepiness with either of catatonia or seizures if found in patients it is appropriate to order antibody assessment before anything else is planned. This needs to be evaluated in a larger sample.
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Affiliation(s)
- S R Chandra
- NIMHANS, Neurology, Department of Neurology, Faculty block, Neurocentre, 560029, Bangalore, Karnataka, India.
| | - Somdattaa Ray
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Thomas Isaac
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Anupama R Pai
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Haripriya Krishnareddy
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Debjyoti Dhar
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Mariamma Philip
- Associate Professor of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru - 560029, Karnataka, India.
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14
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Jiang Y, Tian X, Gu Y, Li F, Wang X. Application of Plasma Exchange in Steroid-Responsive Encephalopathy. Front Immunol 2019; 10:324. [PMID: 30873174 PMCID: PMC6400967 DOI: 10.3389/fimmu.2019.00324] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/07/2019] [Indexed: 12/18/2022] Open
Abstract
Plasma exchange has been widely used in autoimmune neurological diseases and is the standard treatment for myasthenia gravis crisis and Guillain-Barre syndrome. A growing body of research suggests that, in the clinical application of steroid-responsive encephalopathy, such as for Hashimoto's encephalopathy, limbic encephalitis, systemic lupus erythematosus encephalopathy, ANCA-associated vasculitis encephalopathy, and acute disseminated encephalomyelitis, plasma exchange is a safe, and effective option when steroids or other immunosuppressive therapies are ineffective in the short term or when contraindications are present. Additionally, plasma exchange can also be used alone or in combination with steroids, immunoglobulins, or other immunosuppressive agents to treat steroid-responsive encephalopathy. This paper reviews the clinical application of plasma exchange in steroid-responsive encephalopathy, including its indications, onset time, course, curative effects, and side effects.
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Affiliation(s)
- Yuting Jiang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Tian
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yixue Gu
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Li
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuefeng Wang
- Chongqing Key Laboratory of Neurology, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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15
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Nagano M, Kobayashi K, Yamada-Otani M, Kuzuya A, Matsumoto R, Oita J, Yoneda M, Ikeda A, Takahashi R. Hashimoto's Encephalopathy Presenting with Smoldering Limbic Encephalitis. Intern Med 2019; 58:1167-1172. [PMID: 30982805 PMCID: PMC6522399 DOI: 10.2169/internalmedicine.1289-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Hashimoto's encephalopathy (HE) is a steroid-responsive autoimmune encephalopathy associated with Hashimoto thyroiditis. We herein report a case of HE manifesting "smoldering" limbic encephalitis with persisting symptoms and abnormalities on examinations. Although our patient experienced partial clinical remission after treatment, hippocampal hypermetabolism on [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) and subclinical seizures on video electroencephalography persisted. Hypermetabolism on FDG-PET was improved by additional prednisolone therapy. Thus, as with other autoimmune limbic encephalitis cases, HE can take a course of "smoldering" encephalitis. FDG-PET and electroencephalogram findings can reflect the disease activity degree in such patients, although with certain neurophysiological and biochemical distinctions.
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Affiliation(s)
- Masahiro Nagano
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Mayumi Yamada-Otani
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Akira Kuzuya
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Jiro Oita
- Department of Neurology, Shimizu Hospital, Japan
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Sciences, Fukui Prefectural University, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
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16
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Bing-Lei W, Jia-Hua Z, Yan L, Zan Y, Xin B, Jian-Hua S, Hui-Juan W. Three cases of antibody-LGI1 limbic encephalitis and review of literature. Int J Neurosci 2018; 129:642-648. [PMID: 30112956 DOI: 10.1080/00207454.2018.1512985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Antibody-LGI1 limbic encephalitis (LGI1-Ab LE) is an anti-neuronal surface antigen-related autoimmune encephalitis. we report three cases of LGI1-Ab LE, describe the characteristics of clinical manifestation, course of evolution, imaging manifestation and treatment outcomes. METHODS Data from patients diagnosed with LGI1-Ab LE in the Second Hospital, Hebei Medical University, from June 2016 to July 2017, were retrospectively collected and analyzed. We followed up the patients for 90 days. RESULTS Two of the three patients were females, the average age of onset is 53 years old. Epilepsy is the most common clinical manifestations, and one of patients developed faciobrachial dystonic seizures (FBDS), which was recently described as a characteristic feature of LGI1-Ab LE. All patients had cognitive impairment in different degrees and abnormal signal of hippocampus in cranial MRI. All serum LGI1 antibodies were positive, whereas one LGI1 antibodies of CSF were negative. All patients accepted first-line immune therapy and had a good outcome. CONCLUSION LGI1-Ab LE, which is an autoimmune disease, is rare clinically and mostly nonparaneoplastic. We suggest that LGI1-Ab LE be considered in any patient with acute or subacute onset, cognitive dysfunction , various types of seizures, accompanied by mental disorders and hyponatremia, MR showed the involvement of the limbic system. It is necessary to have LE-related antibodies tested. Early immunotherapy can significantly improve the patient's overall prognosis. At the same time, we should also pay attention to the possibility of potential tumors.
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Affiliation(s)
- Wang Bing-Lei
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Zheng Jia-Hua
- b Department of Reproduction Medicine , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Li Yan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Yue Zan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Bian Xin
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Shen Jian-Hua
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
| | - Wang Hui-Juan
- a Department of Neurology , Second Hospital, Hebei Medical University , Shijiazhuang , Hebei , China
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Eyre M, Hacohen Y, Barton C, Hemingway C, Lim M. Therapeutic plasma exchange in paediatric neurology: a critical review and proposed treatment algorithm. Dev Med Child Neurol 2018; 60:765-779. [PMID: 29856068 DOI: 10.1111/dmcn.13925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED Therapeutic plasma exchange (TPE) has been a key immunotherapeutic strategy in numerous neurological syndromes, predominantly during the acute phase of illness. This paper reviews the indications, strength of evidence, and safety of TPE in children with neurological conditions. The rarity of these immune conditions in children, alongside an often incomplete understanding of their pathobiology, has limited the development of a robust scientific rationale for TPE therapy and the feasibility of conducting larger controlled trials. TPE continues to be used, but is a costly therapy with common adverse effects. Uncertainty remains over how to compare the different TPE methods, the optimal dosage of therapy, and monitoring and integration of TPE with other immunotherapies. Further studies are also required to define the indications and benefits of TPE and assess evolving technologies such as immunoadsorption. WHAT THIS PAPER ADDS Studies investigating therapeutic plasma exchange (TPE) are small and mainly uncontrolled. They provide evidence for the efficacy of TPE in childhood neuro-inflammatory conditions. TPE is generally well tolerated provided key adverse effects are anticipated and avoided. Systematic dosing and objective assessment of treatment effect should be priorities for future research.
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Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Carmen Barton
- Children's Kidney Service, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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18
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Autoimmune encephalitis associated with two antibodies. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:44-46. [PMID: 29928585 PMCID: PMC6008288 DOI: 10.1016/j.ebcr.2018.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/28/2018] [Accepted: 04/02/2018] [Indexed: 01/17/2023]
Abstract
•In patients presenting with clinical manifestations of encephalitis without clinical or laboratory signs of infection, an autoimmune etiology should be suspected.•Antibodies for various neural antigens may coexist, thus a complete and clinically-guided autoimmune panel must be done in suspected cases of autoimmune encephalitis.•Tumor resection, if applicable, combined with high dose steroids and immunotherapy are effective treatment strategies for autoimmune encephalitis with coexisting antibodies.
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19
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20
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21
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Fang Z, Yang Y, Chen X, Zhang W, Xie Y, Chen Y, Liu Z, Yuan W. Advances in Autoimmune Epilepsy Associated with Antibodies, Their Potential Pathogenic Molecular Mechanisms, and Current Recommended Immunotherapies. Front Immunol 2017; 8:395. [PMID: 28487693 PMCID: PMC5403900 DOI: 10.3389/fimmu.2017.00395] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/21/2017] [Indexed: 01/17/2023] Open
Abstract
In this comprehensive article, we present an overview of some most common autoimmune antibodies believed to be potentially pathogenic for autoimmune epilepsies and elaborate their pathogenic mode of action in molecular levels based on the existing knowledge. Findings of the studies of immunemodulatory treatments for epilepsy are also discussed, and guidelines for immunotherapy are sorted out. We aim to summarize the emerging understanding of different pathogenic mechanisms of autoantibodies and clinical immunotherapy regimens to open up therapeutic possibilities for future optimum therapy. We conclude that early diagnosis of autoimmune epilepsy is of great significance, as early immune treatments have useful disease-modifying effects on some epilepsies and can facilitate the recovery.
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Affiliation(s)
- Zhiwei Fang
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China.,School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Yunqi Yang
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China.,Zhiyuan College, Shanghai Jiao Tong University, Shanghai, China
| | - Xuan Chen
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Weiwang Zhang
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Yangmei Xie
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yinghui Chen
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Weien Yuan
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
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22
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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23
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von Rhein B, Wagner J, Widman G, Malter MP, Elger CE, Helmstaedter C. Suspected antibody negative autoimmune limbic encephalitis: outcome of immunotherapy. Acta Neurol Scand 2017; 135:134-141. [PMID: 26940288 DOI: 10.1111/ane.12575] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Whether and when to immunologically treat epilepsy patients with suggested autoantibody (AB)-negative limbic encephalitis (LE) is clinically challenging. Therefore, we evaluated the clinical outcome and eventual outcome predictors of immunotherapy in a group of AB-negative patients with recent-onset temporal lobe epilepsy (TLE), magnetic resonance imaging (MRI) indicators of LE, subjective cognitive decline, and/or psychiatric symptoms. METHODS This retrospective, observational, uncontrolled study monitored 28 TLE patients with suggested AB-negative LE along with methylprednisolone immunotherapy. RESULTS All patients had seizures, amygdala and/or -hippocampal enlargement, subjective cognitive decline and/or behavioral problems. Eighty-six percent (24/28) were impaired in executive or memory functions, 39% (10/25) depressed, 81% were on antiepileptic drugs when pulse therapy started. After a median follow-up of 18 months, 46% (13/28) of the patients were seizure free (>2 months), 48% (13/27) showed MRI improvements (amygdala and/or hippocampal volume reduction), cognition improved in 57% (16/28), worsened in 32% (9/28), mood improved in 14% (4/25), and deteriorated in 11% (3/25). Immunotherapy was discontinued in 75% (21/28). Clinical changes did not correlate to each other. Outcomes could not be predicted. CONCLUSION Immunological treatment of suggested AB-negative LE showed reasonable seizure control, MRI and cognitive improvements. Treatment success was not predictable from clinical features, nor definitely attributable to immunological treatment. Lacking biomarkers for the reliable diagnosis of AB-negative LE, we suggest that in presence of mild manifestations, and after initiating antiepileptic drug therapy, negative dynamics in MRI, seizures, cognition, and behavior should be documented before immunosuppressive treatment is initiated.
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Affiliation(s)
- B. von Rhein
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - J. Wagner
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - G. Widman
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - M. P. Malter
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - C. E. Elger
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - C. Helmstaedter
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
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24
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Lascano AM, Korff CM, Picard F. Seizures and Epilepsies due to Channelopathies and Neurotransmitter Receptor Dysfunction: A Parallel between Genetic and Immune Aspects. Mol Syndromol 2016; 7:197-209. [PMID: 27781030 DOI: 10.1159/000447707] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Despite intensive research activity leading to many important discoveries, the pathophysiological mechanisms underlying seizures and epilepsy remain poorly understood. An important number of specific gene defects have been related to various forms of epilepsies, and autoimmunity and epilepsy have been associated for a long time. Certain central nervous system proteins have been involved in epilepsy or acute neurological diseases with seizures either due to underlying gene defects or immune dysfunction. Here, we focus on 2 of them that have been the object of particular attention and in-depth research over the past years: the N-methyl-D-aspartate receptor and the leucin-rich glioma-inactivated protein 1 (LGI1). We also describe illustrative examples of situations in which genetics and immunology meet in the complex pathways that underlie seizures and epilepsy.
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Affiliation(s)
- Agustina M Lascano
- EEG and Epilepsy Exploration Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Christian M Korff
- Pediatric Neurology Unit, Child and Adolescent Department, University Hospitals Geneva, Geneva, Switzerland
| | - Fabienne Picard
- EEG and Epilepsy Exploration Unit, University Hospitals Geneva, Geneva, Switzerland
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25
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Bakpa OD, Reuber M, Irani SR. Antibody-associated epilepsies: Clinical features, evidence for immunotherapies and future research questions. Seizure 2016; 41:26-41. [PMID: 27450643 PMCID: PMC5042290 DOI: 10.1016/j.seizure.2016.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The growing recognition of epilepsies and encephalopathies associated with autoantibodies against surface neuronal proteins (LGI1, NMDAR, CASPR2, GABABR, and AMPAR) means that epileptologists are increasingly asking questions about mechanisms of antibody-mediated epileptogenesis, and about the use of immunotherapies. This review summarizes clinical and paraclinical observations related to autoimmune epilepsies, examines the current evidence for the effectiveness of immunotherapy, and makes epilepsy-specific recommendations for future research. METHOD Systematic literature search with summary and review of the identified publications. Studies describing the clinical characteristics of autoantibody-associated epilepsies and treatments are detailed in tables. RESULTS Literature describing the clinical manifestations and treatment of autoimmune epilepsies associated with neuronal cell-surface autoantibodies (NSAbs) is largely limited to retrospective case series. We systematically summarize the features of particular interest to epileptologists dividing patients into those with acute or subacute encephalopathies associated with epilepsy, and those with chronic epilepsy without encephalopathy. Available observational studies suggest that immunotherapies are effective in some clinical circumstances but outcome data collection methods require greater standardization. CONCLUSIONS The clinical experience captured suggests that clusters of clinical features associate well with specific NSAbs. Intensive and early immunotherapy is indicated when patients present with autoantibody-associated encephalopathies. It remains unclear how patients with chronic epilepsy and the same autoantibodies should be assessed and treated. Tables in this paper provide a comprehensive resource for systematic descriptions of both clinical features and treatments, and highlight limitations of current studies.
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Affiliation(s)
- Ochuko D Bakpa
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DS, UK.
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26
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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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27
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Britton PN, Eastwood K, Paterson B, Durrheim DN, Dale RC, Cheng AC, Kenedi C, Brew BJ, Burrow J, Nagree Y, Leman P, Smith DW, Read K, Booy R, Jones CA. Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand. Intern Med J 2016; 45:563-76. [PMID: 25955462 DOI: 10.1111/imj.12749] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/17/2015] [Indexed: 02/06/2023]
Abstract
Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?
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Affiliation(s)
- P N Britton
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
| | - K Eastwood
- Health Protection, Hunter New England Population Health, Newcastle, New South Wales, Australia.,Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - B Paterson
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - D N Durrheim
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - R C Dale
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - C Kenedi
- Departments of, General Medicine, Auckland City Hospital, Auckland, New Zealand, USA.,Liaison Psychiatry, Auckland City Hospital, Auckland, New Zealand, USA.,Department of Medicine and Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA
| | - B J Brew
- St Vincent's Centre for applied medical research, University of New South Wales, Sydney, Australia.,Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - J Burrow
- Department of Neurology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Y Nagree
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - P Leman
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Royal Perth Hospital, Perth, Australia
| | - D W Smith
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
| | - K Read
- Department of Infectious Diseases, North Shore Hospital, Auckland, New Zealand, USA
| | - R Booy
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia.,National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, Australia
| | - C A Jones
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
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Dogan Onugoren M, Golombeck KS, Bien C, Abu-Tair M, Brand M, Bulla-Hellwig M, Lohmann H, Münstermann D, Pavenstädt H, Thölking G, Valentin R, Wiendl H, Melzer N, Bien CG. Immunoadsorption therapy in autoimmune encephalitides. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e207. [PMID: 26977423 PMCID: PMC4772911 DOI: 10.1212/nxi.0000000000000207] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 12/15/2015] [Indexed: 12/19/2022]
Abstract
Objective: It was hypothesized that in encephalitides with autoantibodies directed to CNS surface antigens an antibody-removing intervention might speed up recovery. Methods: The outcome of autoimmune encephalitis in 19 patients with antibodies against surface antigens (leucine-rich, glioma inactivated 1 [LGI1], n = 3; contactin-associated protein-2 [CASPR2], n = 4; NMDA receptor [NMDAR], n = 7) and intracellular antigens (glutamic acid decarboxylase [GAD], n = 5) after immunoadsorption in addition to corticosteroid therapy was evaluated retrospectively. Modified Rankin scale (mRS) scores and data on seizures, memory, and antibody titers directly after immunoadsorption (early follow-up) and after a median of 4 months (late follow-up) were compiled. Results: Immediately after immunoadsorption, 9 of 14 patients with antibodies against LGI1, CASPR2, or NMDAR (64%), but none with GAD antibodies, had improved by at least one mRS point. Five of the 7 patients with LGI1 or CASRP2 antibodies had become seizure-free, and 2 patients with NMDAR antibodies had a memory improvement of more than 1 SD of a normal control population. At late follow-up, 12 of 14 patients with surface antibodies had improved (86%), and none of the patients with GAD antibodies. Conclusions: It is suggested that addition of immunoadsorption to immunosuppression therapy in patients with surface antibodies may accelerate recovery. This supports the pathogenic role of surface antibodies. Classification of evidence: This study provides Class IV evidence that immunoadsorption combined with immunosuppression therapy is effective in patients with autoimmune encephalitis with surface antibodies.
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Affiliation(s)
- Müjgan Dogan Onugoren
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Kristin S Golombeck
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Corinna Bien
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Mariam Abu-Tair
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Marcus Brand
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Michael Bulla-Hellwig
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Hubertus Lohmann
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Dieter Münstermann
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Hermann Pavenstädt
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Gerold Thölking
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Rainer Valentin
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Heinz Wiendl
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Nico Melzer
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
| | - Christian G Bien
- Epilepsy Center Bethel (M.D.O., C.B., M.B.-H., C.G.B.), Krankenhaus Mara, Bielefeld; Department of Neurology (M.D.O.), University Hospital Erlangen; Department of Neurology (K.S.G., H.L., H.W., N.M.), University of Münster; Department of Nephrology (M.A.-T., R.V.), Bethel-EvKB, Bielefeld; Department of Medicine D (M.B., H.P., G.T.), Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster; and Laboratory Krone (D.M.), Bad Salzuflen, Germany
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Therapeutic Plasma Exchange in Patients with Neurologic Disorders: Review of 63 Cases. Indian J Hematol Blood Transfus 2016; 33:97-105. [PMID: 28194064 DOI: 10.1007/s12288-016-0661-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/16/2016] [Indexed: 12/16/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is a procedure that reduces circulating autoantibodies of the patients. TPE is commonly used in neurological disorders where autoimmunity plays a major role. We report our experience with regard to the indications, adverse events and outcomes of plasma exchange in neurological disorders. Sixty-three patients were included to this retrospective study. Median age was 48 years (range 1-85), there was a predominance of males. Neurological indications included Guillain-Barrè syndrome (n = 22), myasthenia gravis (n = 21), chronic inflammatory demyelinating polyneuropathy (n = 7), polymyositis (n = 3), multifocal motor neuropathy (n = 2), acute disseminated encephalomyelitis (n = 2), neuromyelitis optica (n = 2), multiple sclerosis (n = 2), limbic encephalitis (n = 1) and transverse myelitis (n = 1). TPE was frontline therapy in 57 % of the patients (n = 36). Total number of TPE sessions was 517; median number of sessions per patient was 8 (range 1-66). TPE was done through a central venous access in 97 % and through a peripheral venous access in 3 % of the patients. Human albumin was used as replacement fluid in 49 %, hydroxyethyl starch (HES) in 49 % and fresh frozen plasma in 2 % of the cases. Adverse reactions were recorded in 60 % of the patients. Total ratio of complications in 517 TPE procedures was 10.8 % and these were mild and manageable such as allergic reactions and hypotension. Overall response rate was 81 %. Interestingly, complication and response rates were similar in both HES and human albumin groups. We conclude that TPE is an effective treatment in neurologic diseases in which autoimmunity plays an important role in the pathogenesis and HES can be used instead of albumin as replacement fluid in these disorders, since it is cost-effective, has similar efficacy and complication rates.
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Abstract
Over the last 15 years it has become clear that rare but highly recognizable diseases of the central nervous system (CNS), including newly identified forms of limbic encephalitis and other encephalopathies, are likely to be mediated by antibodies (Abs) to CNS proteins. The Abs are directed against membrane receptors and ion channel-associated proteins that are expressed on the surface of neurons in the CNS, such as N-methyl D-aspartate receptors and leucine-rich, glioma inactivated 1 protein and contactin-associated protein like 2, that are associated with voltage-gated potassium channels. The diseases are not invariably cancer-related and are therefore different from the classical paraneoplastic neurological diseases that are associated with, but not caused by, Abs to intracellular proteins. Most importantly, the new antibody-associated diseases almost invariably respond to immunotherapies with considerable and sometimes complete recovery, and there is convincing evidence of their pathogenicity in the relatively limited studies performed so far. Treatments include first-line steroids, intravenous immunoglobulins, and plasma exchange, and second-line rituximab and cyclophosphamide, followed in many cases by steroid-sparing agents in the long-term. This review focuses mainly on N-methyl D-aspartate receptor- and voltage-gated potassium channel complex-related Abs in adults, the clinical phenotypes, and treatment responses. Pediatric cases are referred to but not reviewed in detail. As there have been very few prospective studies, the conclusions regarding immunotherapies are based on retrospective studies.
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Affiliation(s)
- Matteo Gastaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- University of Pavia, Pavia, Italy.
| | - Anaïs Thouin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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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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Sleep disturbances in voltage-gated potassium channel antibody syndrome. Sleep Med 2015; 21:171-3. [PMID: 26922624 DOI: 10.1016/j.sleep.2015.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/10/2015] [Accepted: 11/16/2015] [Indexed: 01/17/2023]
Abstract
Voltage-gated potassium channels (VGKCs) are a family of membrane proteins responsible for controlling cell membrane potential. The presence of antibodies (Ab) against neuronal VGKC complexes aids in the diagnosis of idiopathic and paraneoplastic autoimmune neurologic disorders. The diagnosis of VGKC Ab-associated encephalopathy (VCKC Ab syndrome) should be suspected in patients with subacute onset of disorientation, confusion, and memory loss in the presence of seizures or a movement disorder. VGKC Ab syndrome may present with sleep-related symptoms, and the purpose of this communication is to alert sleep and neurology clinicians of this still-under-recognized condition. In this case, we are presenting the VGKC Ab syndrome which improved after treatment with solumedrol. The prompt recognition and treatment of this condition may prevent the morbidity associated with cerebral atrophy and the mortality associated with intractable seizures and electrolyte disturbances.
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Casault C, Alikhani K, Pillay N, Koch M. Jerking & confused: Leucine-rich glioma inactivated 1 receptor encephalitis. J Neuroimmunol 2015; 289:84-6. [PMID: 26616875 DOI: 10.1016/j.jneuroim.2015.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/17/2015] [Indexed: 01/17/2023]
Abstract
This is a case of autoimmune encephalitis with features of faciobrachial dystonic seizures (FBDS) pathognomonic for Leucine Rich Glioma inactivated (LGI)1 antibody encephalitis. This voltage-gated potassium channel complex encephalitis is marked by rapid onset dementia, FBDS and hyponatremia, which is sensitive to management with immunotherapy including steroids, IVIG and other agents. In this case report we review the clinical features, imaging and management of this condition.
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Affiliation(s)
- Colin Casault
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Katayoun Alikhani
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neelan Pillay
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Koch
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Reintjes W, Romijn MD, Hollander D, ter Bruggen JP, van Marum RJ. Reversible Dementia: Two Nursing Home Patients With Voltage-Gated Potassium Channel Antibody-Associated Limbic Encephalitis. J Am Med Dir Assoc 2015; 16:790-4. [DOI: 10.1016/j.jamda.2015.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 06/04/2015] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Neurological complications, especially encephalopathy and seizures, are commonly seen in bone marrow transplant patients. Infections, chemotoxicity, graft versus host disease, or secondary central nervous system malignancies are the most common underlying etiologies. There is increased awareness that autoimmune encephalitis may cause neurological dysfunction in immunocompetent children. The potential role of such a mechanism in children undergoing bone marrow transplantation is unknown. METHODS We report a boy who developed autoimmune encephalitis with voltage-gated potassium channel-associated and thyroid autoantibodies subsequent to transplantation. RESULTS A 7-year-old boy presented with a change in behavior, poor attention, cognitive deficits, and abnormal movements 15 months after undergoing transplantation for idiopathic aplastic anemia. He had clinical and subclinical seizures and brain magnetic resonance imaging hyperintensities bilaterally in the uncal regions. His evaluation revealed high titers of voltage-gated potassium channel, leucine-rich glioma-inactivated 1 protein, and thyroglobulin antibodies suggestive of autoimmune limbic encephalitis. He showed significant improvement in behavior and neuropsychological testing and has remained seizure-free on levetiracetam after immunotherapy with corticosteroids and intravenous immunoglobulin. CONCLUSION Systemic autoimmune manifestations in bone marrow transplant patients have been well-documented, but autoimmune encephalitis after transplantation has yet to be described in children.
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Affiliation(s)
- Geetanjali S Rathore
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Kathryn S Leung
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Eyal Muscal
- Department of Pediatric Medicine, Sections of Immunology, Allergy & Rheumatology and Child Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Sühs KW, Wegner F, Skripuletz T, Trebst C, Tayeb SB, Raab P, Stangel M. Heterogeneity of clinical features and corresponding antibodies in seven patients with anti-NMDA receptor encephalitis. Exp Ther Med 2015; 10:1283-1292. [PMID: 26622479 PMCID: PMC4577954 DOI: 10.3892/etm.2015.2689] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 07/10/2015] [Indexed: 12/25/2022] Open
Abstract
Anti-N-methyl D-aspartate (NMDA) receptor encephalitis is the most common type of encephalitis in the spectrum of autoimmune encephalitis defined by antibodies targeting neuronal surface antigens. In the present study, the clinical spectrum of this disease is presented using instructive cases in correlation with the anti-NMDA receptor antibody titers in the cerebrospinal fluid (CSF) and serum. A total of 7 female patients admitted to the hospital of Hannover Medical School (Hannover, Germany) between 2008 and 2014 were diagnosed with anti-NMDA receptor encephalitis. Among these patients, 3 cases were selected to illustrate the range of similar and distinct clinical features across the spectrum of the disease and to compare anti-NMDA antibody levels throughout the disease course. All patients received immunosuppressive treatment with methylprednisolone, intravenous immunoglobulin and/or plasmapheresis, followed in the majority of patients by second-line therapy with rituximab and cyclophosphamide. The disease course correlated with NMDA receptor antibody titers, and to a greater extent with the ratio between antibody titer and protein concentration. A favorable clinical outcome with a modified Rankin Scale (mRS) score of ≤1 was achieved in 4 patients, 1 patient had an mRS score of 2 after 3 months of observation only, whereas 2 patients remained severely impaired (mRS score 4). Early and aggressive immunosuppressive treatment appears to support a good clinical outcome; however, the clinical signs and symptoms differ distinctively and treatment decisions have to be made on an individual basis.
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Affiliation(s)
- Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
| | - Florian Wegner
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
| | - Said Ben Tayeb
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
| | - Peter Raab
- Department of Neuroradiology, Hannover Medical School, Hannover D-30625, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover D-30625, Germany
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Lin Q, Wang X. Differences in epileptic symptoms depending on the type of autoimmune-mediated limbic encephalitis. Expert Rev Clin Immunol 2015; 11:897-910. [PMID: 26163176 DOI: 10.1586/1744666x.2015.1055253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limbic encephalitis (LE) is an inflammatory disease of the central nervous system that is characterized by the selective involvement of limbic structures. The clinical manifestations of LE include the acute or sub-acute onset of recent memory disorders, mental disorders and seizures. Autoimmune-mediated LE is a major type of non-infectious LE; seizure is a hallmark of this type of LE. The treatment of epilepsy, which is a key factor that affects the prognosis of LE patients, warrants special attention. Understanding the characteristics of epilepsy caused by autoimmune-mediated LE and providing the appropriate treatment will help to improve patients' outcomes. In this article, we extensively review the literature related to autoimmune-mediated LE epidemiology, mechanisms, characteristics and seizure frequency and onset, and we discuss the possible diagnosis and treatment of this disease.
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Affiliation(s)
- Qingxia Lin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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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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Joubert B, Honnorat J. Autoimmune channelopathies in paraneoplastic neurological syndromes. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2015; 1848:2665-76. [PMID: 25883091 DOI: 10.1016/j.bbamem.2015.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 03/10/2015] [Accepted: 04/03/2015] [Indexed: 01/17/2023]
Abstract
Paraneoplastic neurological syndromes and autoimmune encephalitides are immune neurological disorders occurring or not in association with a cancer. They are thought to be due to an autoimmune reaction against neuronal antigens ectopically expressed by the underlying tumour or by cross-reaction with an unknown infectious agent. In some instances, paraneoplastic neurological syndromes and autoimmune encephalitides are related to an antibody-induced dysfunction of ion channels, a situation that can be labelled as autoimmune channelopathies. Such functional alterations of ion channels are caused by the specific fixation of an autoantibody upon its target, implying that autoimmune channelopathies are usually highly responsive to immuno-modulatory treatments. Over the recent years, numerous autoantibodies corresponding to various neurological syndromes have been discovered and their mechanisms of action partially deciphered. Autoantibodies in neurological autoimmune channelopathies may target either directly ion channels or proteins associated to ion channels and induce channel dysfunction by various mechanisms generally leading to the reduction of synaptic expression of the considered channel. The discovery of those mechanisms of action has provided insights on the regulation of the synaptic expression of the altered channels as well as the putative roles of some of their functional subdomains. Interestingly, patients' autoantibodies themselves can be used as specific tools in order to study the functions of ion channels. This article is part of a Special Issue entitled: Membrane channels and transporters in cancers.
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Affiliation(s)
- Bastien Joubert
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372 Lyon Cedex 08, France; INSERM, UMR-S1028, CNRS, UMR-5292, Lyon Neuroscience Research Center, Neuro-Oncology and Neuro-Inflammation Team, 7, Rue Guillaume Paradin, Lyon Cedex 08F-69372, France
| | - Jérôme Honnorat
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372 Lyon Cedex 08, France; INSERM, UMR-S1028, CNRS, UMR-5292, Lyon Neuroscience Research Center, Neuro-Oncology and Neuro-Inflammation Team, 7, Rue Guillaume Paradin, Lyon Cedex 08F-69372, France; National Reference Centre for Paraneoplastic Neurological Diseases, hospices civils de Lyon, hôpital neurologique, 69677 Bron, France; Hospices Civils de Lyon, Neuro-oncology, Hôpital Neurologique, F-69677 Bron, France.
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Abstract
Much of the research for intravenous immunoglobulins (IVIG) use in epilepsy has focused on childhood epilepsies and the results have been inconclusive. As evidence for inflammation in epilepsy and epileptogenesis is accumulating, IVIG might have a role to play in adult epilepsy. Our literature review focuses on the purported mechanisms of IVIG, the link between inflammation and the various causes of adult epilepsy and the different steps of epileptogenesis at which inflammation might play a role. We also review the current clinical evidence supporting IVIG as a treatment for epilepsy in the adult population. Though there is interesting theoretical potential for treatment of refractory epilepsy in adults with IVIG, insufficient evidence exists to support its standard use. The question remains if IVIG should still be considered as an end-of-the-line option for patients with epilepsy poorly responsive to all other treatments.
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Huda S, Wong SH, Pettingill P, O'Connell D, Vincent A, Steiger M. An 11-year retrospective experience of antibodies against the voltage-gated potassium channel (VGKC) complex from a tertiary neurological centre. J Neurol 2014; 262:418-24. [PMID: 25428531 DOI: 10.1007/s00415-014-7588-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/14/2014] [Accepted: 11/15/2014] [Indexed: 01/17/2023]
Abstract
Acquired diseases classically associated with VGKC-complex antibodies include peripheral nerve hyperexcitability (PNH), Morvan's syndrome, limbic encephalitis (LE), and epilepsy. However, not all such patients have VGKC-complex antibodies and antibodies have been reported in patients without a defined immune-mediated syndrome. To analyse the clinical relevance of positive VGKC-complex antibodies requested on the basis of initial clinical suspicion. We retrospectively analysed patients with positive VGKC-complex antibodies (>100 pM) referred to our institution between 2001 and 2011. 1,614 VGKC-complex assays were performed in 1,298 patients. Titres >100 pM were detected in 57/1,298 (4 %) patients. A classic VGKC-complex channelopathy (60 %) was associated with VGKC-complex antibody titres >400 pM (p = 0.0004). LGI1 or CASPR2 antibodies were only detected in classic VGKC-complex channelopathies (LE; n = 3/4 and PNH; n = 1/5). VGKC-complex antibody titres <400 pM were seen with PNH (n = 15/22; 68 %) but also a heterogeneous range of central and/or peripheral nervous system disorders. Electromyography was supportive of PNH in 65 % of cases and symptomatic treatment was beneficial in 46 % of patients. Irrespective of titre, the rate of malignancy in patients with VGKC-complex antibodies was higher than the age-matched national incidence of malignancy (OR 19.9, 95 % CI 8.97-44.0 p<0.0001). Clinical phenotyping and antibody titres >400 pM can help determine VGKC-complex antibody relevance. Antibody titres <400 pM are associated with PNH but also a more heterogeneous clinical spectrum. The antibody association in the latter is of doubtful clinical relevance. The rate of malignancy was significantly higher than the national incidence irrespective of titre.
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Affiliation(s)
- S Huda
- Department of Neurology, Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazarkerley, Liverpool, L9 7LJ, UK,
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Bonello M, Larner AJ, Marson AG. Profound amnesia after temporal lobectomy: an autoimmune process resembling patient h.m.? Case Rep Neurol 2014; 6:251-5. [PMID: 25473398 PMCID: PMC4249997 DOI: 10.1159/000369058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We describe a patient who developed significant cognitive decline with profound amnesia following non-dominant temporal lobectomy for refractory seizures, in whom the original suspicion of structural pathology was revised following the discovery of clinical and neuropathological markers of inflammation, neuropsychological evidence of bilateral involvement, and high titres of antibodies directed against glutamic acid decarboxylase (GAD). This case adds to the evidence that the diagnosis of non-paraneoplastic anti-GAD limbic encephalitis merits consideration in any patient with a refractory seizure disorder and cognitive decline.
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Irani SR, Gelfand JM, Al-Diwani A, Vincent A. Cell-surface central nervous system autoantibodies: clinical relevance and emerging paradigms. Ann Neurol 2014; 76:168-84. [PMID: 24930434 PMCID: PMC4141019 DOI: 10.1002/ana.24200] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 06/13/2014] [Accepted: 06/13/2014] [Indexed: 01/17/2023]
Abstract
The recent discovery of several potentially pathogenic autoantibodies has helped identify patients with clinically distinctive central nervous system diseases that appear to benefit from immunotherapy. The associated autoantibodies are directed against the extracellular domains of cell-surface-expressed neuronal or glial proteins such as LGI1, N-methyl-D-aspartate receptor, and aquaporin-4. The original descriptions of the associated clinical syndromes were phenotypically well circumscribed. However, as availability of antibody testing has increased, the range of associated patient phenotypes and demographics has expanded. This in turn has led to the recognition of more immunotherapy-responsive syndromes in patients presenting with cognitive and behavioral problems, seizures, movement disorders, psychiatric features, and demyelinating disease. Although antibody detection remains diagnostically important, clinical recognition of these distinctive syndromes should ensure early and appropriate immunotherapy administration. We review the emerging paradigm of cell-surface-directed antibody-mediated neurological diseases, describe how the associated disease spectrums have broadened since the original descriptions, discuss some of the methodological issues regarding techniques for antibody detection and emphasize considerations surrounding immunotherapy administration. As these disorders continue to reach mainstream neurology and even psychiatry, more cell-surface-directed antibodies will be discovered, and their possible relevance to other more common disease presentations should become more clearly defined.
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Affiliation(s)
- Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom; Multiple Sclerosis and Neuroinflammation Center, Department of Neurology, University of California, San Francisco, San Francisco, CA
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Outcome of limbic encephalitis with VGKC-complex antibodies: relation to antigenic specificity. J Neurol 2014; 261:1695-705. [PMID: 24935858 DOI: 10.1007/s00415-014-7408-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/05/2014] [Accepted: 06/06/2014] [Indexed: 01/12/2023]
Abstract
In limbic encephalitis (LE) with antibodies (Abs) to the voltage-gated potassium channel complex (VGKC), the Abs are mainly directed to the VGKC-complex proteins, leucine-rich, glioma inactivated 1 protein (LGI1) or contactin-associated protein-like 2 (CASPR-2) or neither. Here, we relate the outcomes of VGKC-LE patients to the presence of Abs to LGI1, CASPR-2 or neither antigen (LGI1/CASPR-2-Ab(-)). Clinical, neuropsychology and MRI data were obtained from patient records for all LE patients from the Bonn Epilepsy Centre positive for VGKC-Abs by radioimmunoprecipitation assay between 2002 and 2011. Eighteen VGKC-LE patients were identified: nine patients (50 %) had LGI1-Abs, three (16 %) had CASPR-2-Abs; and six (33 %) were negative for both LGI1- and CASPR-2-Abs. At first assessment, the groups did not differ clinically or radiologically, but faciobrachial dystonic seizures were only observed in two LGI1-Ab(+) patients. All patients received monthly intravenous methylprednisolone (MP) pulses. At the most recent follow up (median 26 months), thirteen (72 %) were seizure-free, and seizure-freedom rates did not differ between the Ab groups. Hippocampal atrophy had developed in 7/9 LGI1-Ab(+) patients, but in none of the CASPR-2-Ab(+) or LGI/CASPR-2-Ab(-) patients (p = 0.003). While all subgroups improved, memory scores only normalized in six patients (33 %) and LGI1-Ab(+) patients were left with significantly poorer memory than the other two subgroups. Most VGKC-LE patients become seizure-free with pulsed monthly MP, but memory outcome is less favourable. Hippocampal atrophy and poor memory recovery is common in patients with LGI1-Abs and suggests permanent functional damage. More intense immunotherapies could improve outcomes in LGI1-Ab(+)-LE.
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IgG and complement deposition and neuronal loss in cats and humans with epilepsy and voltage-gated potassium channel complex antibodies. J Neuropathol Exp Neurol 2014; 73:403-13. [PMID: 24709680 DOI: 10.1097/nen.0000000000000063] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Voltage-gated potassium channel complex (VGKC-complex) antibody (Ab) encephalitis is a well-recognized form of limbic encephalitis in humans, usually occurring in the absence of an underlying tumor. The patients have a subacute onset of seizures, magnetic resonance imaging findings suggestive of hippocampal inflammation, and high serum titers of Abs against proteins of the VGKC-complex, particularly leucine-rich, glioma-inactivated 1 (LGI1). Most patients are diagnosed promptly and recover substantially with immunotherapies; consequently, neuropathological data are limited. We have recently shown that feline complex partial cluster seizures with orofacial involvement (FEPSO) in cats can also be associated with Abs against VGKC-complexes/LGI1. Here we examined the brains of cats with FEPSO and compared the neuropathological findings with those in a human with VGKC-complex-Ab limbic encephalitis. Similar to humans, cats with VGKC-complex-Ab and FEPSO have hippocampal lesions with only moderate T-cell infiltrates but with marked IgG infiltration and complement C9neo deposition on hippocampal neurons, associated with neuronal loss. These findings provide further evidence that FEPSO is a feline form of VGKC-complex-Ab limbic encephalitis and provide a model for increasing understanding of the human disease.
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Napthali K, Boyle M, Tran H, Schofield PW, Peel R, McEvoy M, Oldmeadow C, Attia J. Thyroid antibodies, autoimmunity and cognitive decline: is there a population-based link? Dement Geriatr Cogn Dis Extra 2014; 4:140-6. [PMID: 24987403 PMCID: PMC4067731 DOI: 10.1159/000362716] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Autoimmunity is considered an uncommon but under-recognised cause of cognitive decline. METHODS Serum samples from 3,253 randomly selected subjects enrolled in the Hunter Community Study, aged 55-85 years, were assayed for thyrotropin stimulatory hormone, anti-thyroid peroxidase antibodies (TPO-Ab), anti-nuclear antibodies (ANA) and extractable nuclear antigens (ENA). Cognitive function was assessed using the Audio Recorded Cognitive Screen (ARCS) tool. RESULTS TPO-Ab were found in 8.4% and ANA in 27.9% of the study population, of whom 3% had positive ENA findings. No relationship was found between the ARCS score and either TPO-Ab (coefficient = 0.133; 95% CI -0.20, 0.82, p = 0.616), ANA at a low (coefficient = 1.01; 95% CI -2.58, 0.55, p = 0.203) or a high titre (coefficient = -0.65; 95% CI -2.59, 1.28, p = 0.508), or ENA antibodies (coefficient = 5.12; 95% CI -0.53, 10.77; p = 0.076). CONCLUSIONS Autoantibody findings are common in an aging population and are not associated with cognitive decline.
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Affiliation(s)
- Kate Napthali
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia
| | - Michael Boyle
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia
| | - Huy Tran
- Hunter Area Pathology Service, Newcastle, N.S.W., Australia
| | - Peter W Schofield
- Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, N.S.W., Australia ; Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Neuropsychiatry Unit, Hunter New England Local Health District, Newcastle, N.S.W., Australia
| | - Roseanne Peel
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - Mark McEvoy
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - John Attia
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia ; Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
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Butler CR, Miller TD, Kaur MS, Baker IW, Boothroyd GD, Illman NA, Rosenthal CR, Vincent A, Buckley CJ. Persistent anterograde amnesia following limbic encephalitis associated with antibodies to the voltage-gated potassium channel complex. J Neurol Neurosurg Psychiatry 2014; 85:387-91. [PMID: 24403282 DOI: 10.1136/jnnp-2013-306724] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Limbic encephalitis (LE) associated with antibodies to the voltage-gated potassium channel complex (VGKC) is a potentially reversible cause of cognitive impairment. Despite the prominence of cognitive dysfunction in this syndrome, little is known about patients' neuropsychological profile at presentation or their long-term cognitive outcome. METHODS We used a comprehensive neuropsychological test battery to evaluate cognitive function longitudinally in 19 patients with VGKC-LE. RESULTS Before immunotherapy, the group had significant impairment of memory, processing speed and executive function, whereas language and perceptual organisation were intact. At follow-up, cognitive impairment was restricted to the memory domain, with processing speed and executive function having returned to the normal range. Residual memory function was predicted by the antibody titre at presentation. CONCLUSIONS The results show that, despite broad cognitive dysfunction in the acute phase, patients with VGKC-LE often make a substantial recovery with immunotherapy but may be left with permanent anterograde amnesia.
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Affiliation(s)
- Christopher R Butler
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, , Oxford, UK
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Abstract
In patients with immune-associated disorders of the gray central nervous system matter (including recurrent seizures), antibodies against intracellular antigens have been discovered since the 1980s/1990s. In recent years, new antibodies against surface antigens have also been discovered. In two respects, these antibodies are even more interesting than the ones to intracellular antigens as, first, they promise a better response to immunotherapy; and, second, these antibodies contribute greatly to the understanding of the disease mechanisms. Whereas in encephalitides with antibodies against intracellular antigens, a cytotoxic T-cell-mediated response seems to be responsible for neuronal cell loss, in encephalitides with autoantibodies against surface antigens these antibodies are probably the relevant pathogenic agents in the associated disease conditions. On the one hand, antibodies to the NR1 subunit of N-methyl-D-aspartate receptors have been suggested to cause internalization and loss of these receptors without any cell destruction. This mechanism can explain the reversible functional effects caused by these antibodies. On the other hand, antibody- and complement-mediated destructive, and the irreversible effects of antibodies against the voltage-gated potassium channel antigens have been noted. These emerging findings make it plausible that immunological therapies, preferably early after characterization of the antibodies, offer opportunities to restore the health of affected patients.
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Affiliation(s)
| | - Jan Bauer
- />Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
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Long-term remission with rituximab in refractory leucine-rich glioma inactivated 1 antibody encephalitis. J Neuroimmunol 2014; 271:66-8. [PMID: 24703099 DOI: 10.1016/j.jneuroim.2014.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/12/2014] [Accepted: 03/16/2014] [Indexed: 12/31/2022]
Abstract
Autoimmune encephalitis associated with antibodies to leucine-rich glioma inactivated 1 (LGI1) is recently described and there is a lack of detailed reports on the treatment of relapsing or refractory cases and long-term outcomes. Two case reports are presented. Both cases had faciobrachial dystonic seizures (FBDS) and received rituximab after relapsing or refractory disease. Both cases achieved sustained clinical remission of up to 15 and 56 months respectively. Rituximab use allowed withdrawal of corticosteroids and was well tolerated. Randomized clinical trials are needed in LGI1 encephalitis and other autoimmune encephalitides.
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