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Syk M, Tornvind E, Gallwitz M, Fällmar D, Amandusson Å, Rothkegel H, Danfors T, Thulin M, Rasmusson AJ, Cervenka S, Pollak TA, Endres D, van Elst LT, Bodén R, Nilsson BM, Nordmark G, Burman J, Cunningham JL. An exploratory study of the damage markers NfL, GFAP, and t-Tau, in cerebrospinal fluid and other findings from a patient cohort enriched for suspected autoimmune psychiatric disease. Transl Psychiatry 2024; 14:304. [PMID: 39048548 PMCID: PMC11269634 DOI: 10.1038/s41398-024-03021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 06/27/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024] Open
Abstract
There is growing evidence suggesting that immunological mechanisms play a significant role in the development of psychiatric symptoms in certain patient subgroups. However, the relationship between clinical red flags for suspected autoimmune psychiatric disease and signs of central nervous system (CNS) pathology (e.g., routine cerebrospinal fluid (CSF) alterations, CNS damage markers, neurophysiological or neuroimaging findings) has received limited attention. Here, we aimed to describe the prevalence and distribution of potential CNS pathologies in psychiatric patients in relation to clinical red flags for autoimmune psychiatric disease and psychiatric symptoms. CSF routine findings and CNS damage markers; neurofilament light chain protein (NfL), glial fibrillary acidic protein (GFAP) and total Tau (t-Tau), in CSF from 127 patients with psychiatric disease preselected for suspected immunological involvement were related to recently proposed clinical red flags, psychiatric features, and MRI and EEG findings. Twenty-one percent had abnormal routine CSF findings and 27% had elevated levels of CNS damage markers. Six percent had anti-neuronal antibodies in serum and 2% had these antibodies in the CSF. Sixty-six percent of patients examined with MRI (n = 88) had alterations, mostly atrophy or nonspecific white matter lesions. Twenty-seven percent of patients with EEG recordings (n = 70) had abnormal findings. Elevated NfL levels were associated with comorbid autoimmunity and affective dysregulation symptoms. Elevated t-Tau was associated with catatonia and higher ratings of agitation/hyperactivity. Elevated GFAP was associated with acute onset, atypical presentation, infectious prodrome, tics, depressive/anxiety symptom ratings and overall greater psychiatric symptom burden. In conclusion, preselection based on suspected autoimmune psychiatric disease identifies a population with a high prevalence of CSF alterations suggesting CNS pathology. Future studies should examine the value of these markers in predicting treatment responses.
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Affiliation(s)
- Mikaela Syk
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Emma Tornvind
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Maike Gallwitz
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - David Fällmar
- Department of Surgical Sciences, Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Åsa Amandusson
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Holger Rothkegel
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Torsten Danfors
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Måns Thulin
- Department of Mathematics, Uppsala University, Uppsala, Sweden
| | - Annica J Rasmusson
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Simon Cervenka
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Björn M Nilsson
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Gunnel Nordmark
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Janet L Cunningham
- Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden.
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Endres D, von Zedtwitz K, Nickel K, Runge K, Maier A, Domschke K, Salzer U, Prüss H, Venhoff N, van Elst LT. Association of rheumatological markers with neuronal antibodies, cerebrospinal fluid, electroencephalography, and magnetic resonance imaging findings in 224 patients with psychotic syndromes. Brain Behav Immun 2024; 119:482-493. [PMID: 38599500 DOI: 10.1016/j.bbi.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 03/10/2024] [Accepted: 04/06/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Psychotic syndromes can have autoimmune-mediated causes in some patients. Thus, this retrospective work aims to investigate the role of rheumatological markers in the development of psychosis. PATIENTS AND METHODS In total, 224 patients with psychotic syndromes receiving a "rheumatological laboratory screening" (including C-reactive protein [CRP], immunofixation, complement factors, rheumatoid factor [RF], antiphospholipid antibodies [APAs], antineutrophil cytoplasmic antibodies [ANCAs], and antinuclear antibodies [ANAs]) were analyzed. A further diagnostic work-up included investigations of neuronal antibodies and cerebrospinal fluid (CSF), as well as electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain. ANA testing was routinely performed in all patients using serum on human epithelioma-2 (Hep2) cells, and a subset of patients (N = 73) also underwent tissue-based assays from serum and CSF. The number of cases with autoimmune psychotic syndromes was descriptively collected, and ANA-positive and -negative patients were compared in detail. RESULTS CRP was elevated in 9 % of patients, immunofixation identified alterations in 8 %, complement factor C3 was decreased in 14 %, RF was elevated in 1 %, APAs were elevated in 7 %, ANCAs were not clearly positive, and ANAs were positive in 19 % (extractable nuclear antigen [ENA] differentiation resulted in positive findings in 14 patients). From the 73 patient samples additionally investigated using tissue-based assays, there were 26 positive results for some kind of ANA (36 %), and overall using both methods, 54 patients (24 %) were considered positive for ANAs. A neuropsychiatric evaluation revealed a possible autoimmune psychotic syndrome in seven patients (3 %) and a probable autoimmune psychotic syndrome in two patients (1 %). ANA-positive patients were more frequently treated with antidepressants (p = 0.040) and had a higher number of somatic comorbidities (p < 0.001). In addition, (chronic) inflammatory MRI lesions (p = 0.008) and focal atrophies (p = 0.012) were found more frequently in ANA-positive than ANA-negative patients. DISCUSSION Rheumatological screening led to suspicion of a possible or probable autoimmune psychotic syndrome in 4%. ANAs were associated with MRI pathologies. Therefore, rheumatological processes may contribute to the development of psychotic syndromes in rare cases.
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Affiliation(s)
- Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Katharina von Zedtwitz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kimon Runge
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Maier
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Salzer
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Gangadin SS, Enthoven AD, van Beveren NJM, Laman JD, Sommer IEC. Immune Dysfunction in Schizophrenia Spectrum Disorders. Annu Rev Clin Psychol 2024; 20:229-257. [PMID: 38996077 DOI: 10.1146/annurev-clinpsy-081122-013201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
Evidence from epidemiological, clinical, and biological research resulted in the immune hypothesis: the hypothesis that immune system dysfunction is involved in the pathophysiology of schizophrenia spectrum disorders (SSD). The promising implication of this hypothesis is the potential to use existing immunomodulatory treatment for innovative interventions for SSD. Here, we provide a selective historical review of important discoveries that have shaped our understanding of immune dysfunction in SSD. We first explain the basic principles of immune dysfunction, after which we travel more than a century back in time. Starting our journey with neurosyphilis-associated psychosis in the nineteenth century, we continue by evaluating the role of infections and autoimmunity in SSD and findings from assessment of immune function using new techniques, such as cytokine levels, microglia density, neuroimaging, and gene expression. Drawing from these findings, we discuss anti-inflammatory interventions for SSD, and we conclude with a look into the future.
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Affiliation(s)
- S S Gangadin
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands;
| | - A D Enthoven
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands;
| | - N J M van Beveren
- Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands
- Parnassia Group for Mental Health Care, The Hague and Rotterdam, The Netherlands
| | - J D Laman
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - I E C Sommer
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands;
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Pavăl D, Gherghel-Pavăl N, Căpățînă OO, Stan A, Micluția IV. The relevance of anti-N-methyl-D-aspartate receptor encephalitis for psychiatrists. Int J Psychiatry Clin Pract 2024; 28:73-81. [PMID: 38702981 DOI: 10.1080/13651501.2024.2323926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/20/2024] [Indexed: 05/06/2024]
Abstract
Psychiatrists are often the first to be consulted in patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. While this disease is rare, psychiatrists need to be aware of its relevant fundamental, clinical and therapeutic aspects. We begin by reviewing the connection between anti-NMDAR encephalitis and the glutamate hypothesis of schizophrenia. Next, we focus on the profile of the patient typically afflicted with this disease. Then, we tackle the limited utility of current diagnostic criteria during the early stage of the disease. After reviewing the psychiatric features, we debate the quest for finding specific psychiatric phenotypes that could facilitate early-stage diagnosis. We conclude by discussing the treatment of psychiatric symptoms and disease outcomes. As follows, this paper presents the relevance of anti-NMDAR encephalitis for psychiatrists.
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Affiliation(s)
- Denis Pavăl
- Department of Psychiatry, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Romanian Association for Autoimmune Encephalitis, Cluj-Napoca, Romania
| | | | - Octavia Oana Căpățînă
- Department of Psychiatry, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Romanian Association for Autoimmune Encephalitis, Cluj-Napoca, Romania
| | - Adina Stan
- Department of Neurology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Valentina Micluția
- Department of Psychiatry, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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5
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Neațu M, Jugurt A, Covaliu A, Davidescu EI, Popescu BO. Autoimmune Encephalitis-A Multifaceted Pathology. Biomedicines 2023; 11:2176. [PMID: 37626673 PMCID: PMC10452276 DOI: 10.3390/biomedicines11082176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Autoimmune encephalitis is a complex and multifaceted pathology that involves immune-mediated inflammation of the brain. It is characterized by the body's immune system attacking the brain tissue, leading to a cascade of inflammatory processes. What makes autoimmune encephalitis vast is the wide range of causes, mechanisms, clinical presentations, and diagnostic challenges associated with the condition. The clinical presentations of autoimmune encephalitis are broad and can mimic other neurological disorders, making it a challenging differential diagnosis. This diverse clinical presentation can overlap with other conditions, making it crucial for healthcare professionals to maintain a high level of suspicion for autoimmune encephalitis when evaluating patients. The diagnostic challenges associated with autoimmune encephalitis further contribute to its vastness. Due to the variable nature of the condition, there is no definitive diagnostic test that can confirm autoimmune encephalitis in all cases. In this context, personalized patient management is crucial for achieving favorable outcomes. Each patient's treatment plan should be tailored to their specific clinical presentation, underlying cause, and immune response. Our objective is to raise awareness about the frequent yet underdiagnosed nature of autoimmune encephalitis by sharing five cases we encountered, along with a brief literature review.
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Affiliation(s)
- Monica Neațu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.N.); (A.J.); (A.C.); (B.O.P.)
- Department of Neurology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Ana Jugurt
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.N.); (A.J.); (A.C.); (B.O.P.)
- Department of Neurology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Anca Covaliu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.N.); (A.J.); (A.C.); (B.O.P.)
- Department of Neurology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Eugenia Irene Davidescu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.N.); (A.J.); (A.C.); (B.O.P.)
- Department of Neurology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.N.); (A.J.); (A.C.); (B.O.P.)
- Department of Neurology, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Department of Cell Biology, Neurosciences and Experimental Myology, “Victor Babeș” National Institute of Pathology, 050096 Bucharest, Romania
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Ortega MA, García-Montero C, Fraile-Martinez Ó, De Leon-Oliva D, Boaru DL, Bravo C, De Leon-Luis JA, Saez MA, Asúnsolo A, Romero-Gerechter I, Sanz-Giancola A, Diaz-Pedrero R, Lopez-Gonzalez L, Guijarro LG, Barrena-Blázquez S, Bujan J, García-Honduvilla N, Alvarez-Mon M, Alvarez-Mon MÁ, Lahera G. Assessment of Tissue Expression of the Oxytocin-Vasopressin Pathway in the Placenta of Women with a First-Episode Psychosis during Pregnancy. Int J Mol Sci 2023; 24:10254. [PMID: 37373400 DOI: 10.3390/ijms241210254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Psychosis refers to a mental health condition characterized by a loss of touch with reality, comprising delusions, hallucinations, disorganized thought, disorganized behavior, catatonia, and negative symptoms. A first-episode psychosis (FEP) is a rare condition that can trigger adverse outcomes both for the mother and newborn. Previously, we demonstrated the existence of histopathological changes in the placenta of pregnant women who suffer an FEP in pregnancy. Altered levels of oxytocin (OXT) and vasopressin (AVP) have been detected in patients who manifested an FEP, whereas abnormal placental expression of these hormones and their receptors (OXTR and AVPR1A) has been proven in different obstetric complications. However, the precise role and expression of these components in the placenta of women after an FEP have not been studied yet. Thus, the purpose of the present study was to analyze the gene and protein expression, using RT-qPCR and immunohistochemistry (IHC), of OXT, OXTR, AVP, and AVPR1a in the placental tissue of pregnant women after an FEP in comparison to pregnant women without any health complication (HC-PW). Our results showed increased gene and protein expression of OXT, AVP, OXTR, and AVPR1A in the placental tissue of pregnant women who suffer an FEP. Therefore, our study suggests that an FEP during pregnancy may be associated with an abnormal paracrine/endocrine activity of the placenta, which can negatively affect the maternofetal wellbeing. Nevertheless, additional research is required to validate our findings and ascertain any potential implications of the observed alterations.
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Affiliation(s)
- Miguel A Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Óscar Fraile-Martinez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Diego De Leon-Oliva
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Diego Liviu Boaru
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Coral Bravo
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28007 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Juan A De Leon-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28007 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Miguel A Saez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Pathological Anatomy Service, Central University Hospital of Defence-UAH Madrid, 28801 Alcalá de Henares, Spain
| | - Angel Asúnsolo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Ignacio Romero-Gerechter
- Psychiatry Service, Center for Biomedical Research in the Mental Health Network, University Hospital Príncipe de Asturias, 28801 Alcalá de Henares, Spain
| | - Alejandro Sanz-Giancola
- Psychiatry Service, Center for Biomedical Research in the Mental Health Network, University Hospital Príncipe de Asturias, 28801 Alcalá de Henares, Spain
| | - Raul Diaz-Pedrero
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Laura Lopez-Gonzalez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Luis G Guijarro
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Unit of Biochemistry and Molecular Biology (CIBEREHD), Department of System Biology, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Silvestra Barrena-Blázquez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Nursing and Physiotherapy, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Melchor Alvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases-Rheumatology and Internal Medicine Service, University Hospital Príncipe de Asturias, CIBEREHD, 28806 Alcalá de Henares, Spain
| | - Miguel Ángel Alvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain
| | - Guillermo Lahera
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
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Hiesgen J, Schutte C. Autoimmune encephalitis : Part 1 (Epidemiology, Pathophysiology and Clinical spectrum). S Afr Med J 2023; 113:116-121. [PMID: 36876355 DOI: 10.7196/samj.2023.v113i3.780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Since the identification of anti-N-methyl-D-aspartate (NMDA) receptor antibodies about 15 years ago, many patients with rapidly progressing psychiatric symptoms, abnormal movements, seizures or unexplained coma, have been diagnosed with autoimmune encephalitis (AE). The symptom onset is often unspecific and might mimic psychiatric disease, but the later course is frequently characterized by severe disease, often requiring intensive care. Clinical and immunological criteria are helpful in identifying the patients, but no biomarkers exist to guide the clinician in therapy or predict outcome. While persons of all ages can be affected by AE, some types of AE affect more children and young adults and are more prevalent in women. This review will focus on encephalitides associated with neuronal cell-surface or synaptic antibodies, which can result in characteristic syndromes, and are often recognizable on clinical grounds. AE subtypes associated with antibodies against extracellular epitopes can occur with or without tumours. Because the antibodies bind and alter the function of the antigen, the effects are often reversible if immunotherapy is initiated, and the prognosis is favourable in most instances. The first part of this series will introduce the topic, provide an overview of current neuronal surface antibodies and how they present, describe the most common subtype, anti-NMDA receptor encephalitis, and discuss the difficulties in recognizing patients with underlying AE amongst patients with new onset psychiatric disorders.
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Younger DS. Pediatric neuropsychiatric disorders with motor and nonmotor phenomena. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:367-387. [PMID: 37620079 DOI: 10.1016/b978-0-323-98817-9.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
The concept of pediatric autoimmune neuropsychiatric disorders associated with group A beta-hemolytic streptococcus (PANDAS) has become seminal since first introduced more than two decades ago. At the time of this writing, most neurologists, pediatricians, psychiatrists, and general pediatricians will probably have heard of this association or treated an affected child with PANDAS. The concept of an acute-onset, and typically self-limited, postinfectious autoimmune neuropsychiatric disorder resembling PANDAS manifesting vocal and motor tics and obsessive-compulsive disorder has broadened to other putative microbes and related endogenous and exogenous disease triggers. These disorders with common features of hypometabolism in the medial temporal lobe and hippocampus in brain 18fluorodeoxyglucose positron emission tomography fused to magnetic resonance imaging (FDG PET-MRI), form a spectrum: with the neuropsychiatric disorder Tourette syndrome and PANDAS with its well-defined etiopathogenesis at one end, and pediatric abrupt-onset neuropsychiatric syndrome (PANS), alone or associated with specific bacterial and viral pathogens, at the other end. The designation of PANS in the absence of a specific trigger, as an exclusionary diagnosis, reflects the current problem in nosology.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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9
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Elkjaer Greenwood Ormerod MB, Ueland T, Frogner Werner MC, Hjell G, Rødevand L, Sæther LS, Lunding SH, Johansen IT, Ueland T, Lagerberg TV, Melle I, Djurovic S, Andreassen OA, Steen NE. Composite immune marker scores associated with severe mental disorders and illness course. Brain Behav Immun Health 2022; 24:100483. [PMID: 35856063 PMCID: PMC9287150 DOI: 10.1016/j.bbih.2022.100483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 12/29/2022] Open
Abstract
Background Low-grade inflammation has been implicated in the pathophysiology of severe mental disorders (SMDs) and a link between immune activation and clinical characteristics is suggested. However, few studies have investigated how patterns across immune markers are related to diagnosis and illness course. Methods A total of 948 participants with a diagnosis of schizophrenia (SCZ, N = 602) or bipolar (BD, N = 346) spectrum disorder, and 814 healthy controls (HC) were included. Twenty-five immune markers comprising cell adhesion molecules (CAMs), interleukin (IL)-18-system factors, defensins, chemokines and other markers, related to neuroinflammation, blood-brain barrier (BBB) function, inflammasome activation and immune cell orchestration were analyzed. Eight immune principal component (PC) scores were constructed by PC Analysis (PCA) and applied in general linear models with diagnosis and illness course characteristics. Results Three PC scores were significantly associated with a SCZ and/or BD diagnosis (HC reference), with largest, however small, effect sizes of scores based on CAMs, BBB markers and defensins (p < 0.001, partial η2 = 0.02-0.03). Number of psychotic episodes per year in SCZ was associated with a PC score based on IL-18 system markers and the potential neuroprotective cytokine A proliferation-inducing ligand (p = 0.006, partial η2 = 0.071). Conclusion Analyses of composite immune markers scores identified specific patterns suggesting CAMs-mediated BBB dysregulation pathways associated with SMDs and interrelated pro-inflammatory and neuronal integrity processes associated with severity of illness course. This suggests a complex pattern of immune pathways involved in SMDs and SCZ illness course.
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Affiliation(s)
| | - Thor Ueland
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- KG Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway
| | - Maren Caroline Frogner Werner
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gabriela Hjell
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Psychiatry, Østfold Hospital, Graalum, Norway
| | - Linn Rødevand
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Linn Sofie Sæther
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Synve Hoffart Lunding
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingrid Torp Johansen
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Torill Ueland
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Trine Vik Lagerberg
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Ingrid Melle
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Srdjan Djurovic
- Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
- NORMENT, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ole Andreas Andreassen
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nils Eiel Steen
- NORMENT Centre, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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10
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Sabe M, Sentissi O. Psychotic symptoms prior or concomitant to diagnosis of multiple sclerosis: a systematic review of case reports and case series. Int J Psychiatry Clin Pract 2022; 26:287-293. [PMID: 34487465 DOI: 10.1080/13651501.2021.1973506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to examine the clinical features of psychotic symptoms preceding or concomitant to multiple sclerosis (MS) diagnosis. METHOD From the 1st to 10th of January 2020 a systematic review was conducted through an electronic search of different databases. Results were limited to English, French, German, Italian and Spanish language articles. RESULTS We identified 599 titles, and included 32 cases from case-report and case series. One case report from our department was added. The mean age of first psychiatric symptoms was 25.8 ± 10.2 years, the mean age of MS diagnosis was 31.2 ± 10.7 years and the mean delay until MS diagnosis was 2.7 ± 3 years. Most reported symptoms were delusions (81%), auditory hallucinations (59%) and visual hallucinations (50%). Upon the MS diagnosis, immunosuppressive therapy was significantly more effective for psychotic symptoms than antipsychotics (OR = 9.0; 95%CI: 2.15-37; p = 0.002). Diffuse periventricular lesions were found in 95.6% of cases, with mostly temporal or frontal predominant lesions. In cases affected by predominant temporal lesions, 83% of cases presented visual hallucinations (p < 0.05). CONCLUSION Poor response or resistance to antipsychotics treatment should alert clinicians on the need to consider a differential diagnosis. Considering the impact of delay in MS diagnosis further research regarding this subject is warranted.KEY POINTSInsight into the occurrence of psychotic symptoms in multiple sclerosis (MS) is mainly limited to case reports and case series.Delay in MS management between initial psychotic symptoms and the MS diagnosis is 2.73 ± 3 years and 0.8 ± 1.2 years for patients presenting a first episode of psychosis.The resistance and poor response to antipsychotics found in most cases (75%) were associated with an excellent improvement (95%) of both psychiatric and neurologic symptoms with corticosteroids.Prospective studies are needed to investigate the spectrum of psychosis in MS.
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Affiliation(s)
- Michel Sabe
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Thonex, Switzerland
| | - Othman Sentissi
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Thonex, Switzerland
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11
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Autoimmune Encephalitis: A Physician’s Guide to the Clinical Spectrum Diagnosis and Management. Brain Sci 2022; 12:brainsci12091130. [PMID: 36138865 PMCID: PMC9497072 DOI: 10.3390/brainsci12091130] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
The rapidly expanding spectrum of autoimmune encephalitis in the last fifteen years is largely due to ongoing discovery of many neuronal autoantibodies. The diagnosis of autoimmune encephalitis can be challenging due to the wide spectrum of clinical presentations, prevalence of psychiatric features that mimic primary psychiatric illnesses, frequent absence of diagnostic abnormalities on conventional brain MR-imaging, non-specific findings on EEG testing, and the lack of identified IgG class neuronal autoantibodies in blood or CSF in a subgroup of patients. Early recognition and treatment are paramount to improve outcomes and achieve complete recovery from these debilitating, occasionally life threatening, disorders. This review is aimed to provide primary care physicians and hospitalists who, together with neurologist and psychiatrists, are often the first port of call for individuals presenting with new-onset neuropsychiatric symptoms, with up-to-date data and evidence-based approach to the diagnosis and management of individuals with neuropsychiatric disorders of suspected autoimmune origin.
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12
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Endres D, von Zedtwitz K, Matteit I, Bünger I, Foverskov-Rasmussen H, Runge K, Feige B, Schlump A, Maier S, Nickel K, Berger B, Schiele MA, Cunningham JL, Domschke K, Prüss H, Tebartz van Elst L. Spectrum of Novel Anti-Central Nervous System Autoantibodies in the Cerebrospinal Fluid of 119 Patients With Schizophreniform and Affective Disorders. Biol Psychiatry 2022; 92:261-274. [PMID: 35606187 DOI: 10.1016/j.biopsych.2022.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autoimmune psychosis may be caused by well-characterized anti-neuronal autoantibodies, such as those against the NMDA receptor. However, the presence of additional anti-central nervous system (CNS) autoantibodies in these patients has not been systematically assessed. METHODS Serum and cerebrospinal fluid (CSF) from patients with schizophreniform and affective syndromes were analyzed for immunoglobulin G anti-CNS autoantibodies using tissue-based assays with indirect immunofluorescence on unfixed murine brain tissue as part of an extended routine clinical practice. After an initial assessment of patients with red flags for autoimmune psychosis (n = 30), tissue-based testing was extended to a routine procedure (n = 89). RESULTS Based on the findings from all 119 patients, anti-CNS immunoglobulin G autoantibodies against brain tissue were detected in 18% (n = 22) of patients (serum 9%, CSF 18%) following five principal patterns: 1) against vascular structures, most likely endothelial cells (serum 3%, CSF 8%); 2) against granule cells in the cerebellum and/or hippocampus (serum 4%, CSF 6%); 3) against myelinated fibers (serum 2%, CSF 2%); 4) against cerebellar Purkinje cells (serum 0%, CSF 2%); and 5) against astrocytes (serum 1%, CSF 1%). The patients with novel anti-CNS autoantibodies showed increased albumin quotients (p = .026) and white matter changes (p = .020) more frequently than those who tested negative for autoantibodies. CONCLUSIONS The study demonstrates five novel autoantibody-binding patterns on brain tissue of patients with schizophreniform and affective syndromes. CSF yielded positive findings more frequently than serum analysis. The frequency and spectrum of autoantibodies in these patient groups may be broader than previously thought.
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Affiliation(s)
- Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina von Zedtwitz
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Isabelle Matteit
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Isabel Bünger
- Department of Neurology and Experimental Neurology, Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases Berlin, Berlin, Germany
| | - Helle Foverskov-Rasmussen
- Department of Neurology and Experimental Neurology, Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases Berlin, Berlin, Germany
| | - Kimon Runge
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrea Schlump
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon Maier
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam A Schiele
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janet L Cunningham
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases Berlin, Berlin, Germany.
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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13
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Endres D, Maier V, Leypoldt F, Wandinger KP, Lennox B, Pollak TA, Nickel K, Maier S, Feige B, Domschke K, Prüss H, Bechter K, Dersch R, Tebartz van Elst L. Autoantibody-associated psychiatric syndromes: a systematic literature review resulting in 145 cases. Psychol Med 2022; 52:1135-1146. [PMID: 32892761 PMCID: PMC9069350 DOI: 10.1017/s0033291720002895] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is an important consideration during the diagnostic work-up of secondary mental disorders. Indeed, isolated psychiatric syndromes have been described in case reports of patients with underlying AE. Therefore, the authors performed a systematic literature review of published cases with AE that have predominant psychiatric/neurocognitive manifestations. The aim of this paper is to present the clinical characteristics of these patients. METHODS The authors conducted a systematic Medline search via Ovid, looking for case reports/series of AEs with antineuronal autoantibodies (Abs) against cell surface/intracellular antigens combined with predominant psychiatric/neurocognitive syndromes. The same was done for patients with Hashimoto encephalopathy/SREAT. Only patients with signs of immunological brain involvement or tumors in their diagnostic investigations or improvement under immunomodulatory drugs were included. RESULTS We identified 145 patients with AE mimicking predominant psychiatric/neurocognitive syndromes. Of these cases, 64% were female, and the mean age among all patients was 43.9 (±22.1) years. Most of the patients had Abs against neuronal cell surface antigens (55%), most frequently against the NMDA-receptor (N = 46). Amnestic/dementia-like (39%) and schizophreniform (34%) syndromes were the most frequently reported. Cerebrospinal fluid changes were found in 78%, electroencephalography abnormalities in 61%, and magnetic resonance imaging pathologies in 51% of the patients. Immunomodulatory treatment was performed in 87% of the cases, and 94% of the patients responded to treatment. CONCLUSIONS Our findings indicate that AEs can mimic predominant psychiatric and neurocognitive disorders, such as schizophreniform psychoses or neurodegenerative dementia, and that affected patients can be treated successfully with immunomodulatory drugs.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frank Leypoldt
- Neuroimmunology Section, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel/Lübeck, Kiel/Lübeck, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology Section, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel/Lübeck, Kiel/Lübeck, Germany
| | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Thomas A. Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Basics in NeuromodulationUniversity of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Karl Bechter
- Clinic for Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Rick Dersch
- Department for Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Li J, Yoshikawa A, Alliey-Rodriguez N, Meltzer HY. Schizophrenia risk loci from xMHC region were associated with antipsychotic response in chronic schizophrenic patients with persistent positive symptom. Transl Psychiatry 2022; 12:92. [PMID: 35250027 PMCID: PMC8898944 DOI: 10.1038/s41398-022-01854-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/17/2021] [Accepted: 02/03/2022] [Indexed: 11/09/2022] Open
Abstract
We examined whether common variants from the extended major histocompatibility complex (xMHC) region contribute to the response to antipsychotic drugs (APDs) in patients with schizophrenia with persistent psychosis. Subjects participated in a prospective longitudinal study of the effect of APDs on psychopathology were temporally split into discovery (n = 88) and replication (n = 42) cohorts. The primary endpoint was a change in Brief Psychiatric Rating Scale at 6-week or 6-month after treatment. rs204991 (β = 3.917, p = 3.72 × 10-6), the strongest signal associated with response at 6-week was located near C4A/C4B after a linear regression adjusted for covariates. xMHC SNP imputation disclosed much stronger signals (rs9268469, β = 5.140, p = 1.57 × 10-7) and other weaker signals (p < 1 × 10-5) spanning the entire xMHC region. All the variants were previously identified schizophrenia risk loci. Conditional fine-mapping revealed three subgroups of SNPs which were the eQTLs (p < 1 × 10-7) for C4A, HLA-C, and BTN3A2 in disease-relevant tissue. Epistasis between HLA-C and C4A was observed (p = 0.019). Minor allele (G) carriers of rs204991, eQTL for C4A, having decreased risk for schizophrenia and lower imputed expression of C4A, had a better response to APDs. Some imputed HLA alleles associated with a decreased risk for schizophrenia had a positive association with improvement in psychotic symptoms. An independent cohort validated the association of change in psychosis with C4A. We provide evidence that genetic risk factors for schizophrenia from the xMHC region are associated with response to APDs and those variants significantly alter the imputed expression of C4A, HLA-C, and BTN3A2. The minor alleles predicting higher C4A level are associated with diminished improvement in psychotic symptoms after APD treatment.
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Affiliation(s)
- Jiang Li
- grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.415341.60000 0004 0433 4040Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA USA
| | - Akane Yoshikawa
- grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.258269.20000 0004 1762 2738Department of Psychiatry and Behavioral Sciences, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ney Alliey-Rodriguez
- grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Herbert Y. Meltzer
- grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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15
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Butler M, Cross B, Hafeez D, Lim MF, Morrin H, Rengasamy ER, Pollak T, Nicholson TR. Emerging Knowledge of the Neurobiology of COVID-19. Psychiatr Clin North Am 2022; 45:29-43. [PMID: 35219440 PMCID: PMC8580843 DOI: 10.1016/j.psc.2021.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Many patients with COVID-19 will experience acute or longer-term neuropsychiatric complications. The neurobiological mechanisms behind these are beginning to emerge; however, the neurotropic hypothesis is not strongly supported by clinical data. The inflammatory response to SARS-CoV-2 is likely to be responsible for delirium and other common acute neuropsychiatric manifestations. Vascular abnormalities such as endotheliopathies contribute to stroke and cerebral microbleeds, with their attendant neuropsychiatric sequelae. Longer-term neuropsychiatric syndromes fall into 2 broad categories: neuropsychiatric deficits occurring after severe (hospitalized) COVID-19 and "long COVID," which occurs in many patients with a milder acute COVID-19 illness.
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Affiliation(s)
- Matthew Butler
- Institute of Psychiatry, Psychology and Neuroscience, King's College, 16 De Crespigny Park, SE5 8AF London.
| | - Benjamin Cross
- East Lancashire Hospitals NHS Trust, Casterton Ave, Burnley, BB10 2PQ
| | - Danish Hafeez
- School of Medical Sciences, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
| | - Mao Fong Lim
- Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Hamilton Morrin
- Maidstone & Tunbridge Wells NHS Trust, Tonbridge Rd, Royal Tunbridge Wells, TN2 4QJ, UK
| | - Emma Rachel Rengasamy
- Cwm Taf Morgannwg University Health Board, Ynysmeurig House, Navigation Park, Abercynon, CF45 4SN, UK
| | - Tom Pollak
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, 16 De Crespigny Park, SE5 8AF London
| | - Timothy R. Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, 16 De Crespigny Park, SE5 8AF London
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16
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Anti-NMDA Receptor Encephalitis: A Challenge in Psychiatric Settings. J Psychiatr Pract 2022; 28:78-83. [PMID: 34989350 DOI: 10.1097/pra.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a condition that was only identified relatively recently. It often presents in psychiatric settings, with clinical presentations that may overlap with those of other psychiatric disorders such as psychoses secondary to schizophrenia, substance use, or brief delusional disorder. It often presents in women of child bearing age and has a relatively high mortality rate. The treatment approach for anti-NMDA receptor encephalitis is considerably different from that used for other psychiatric and neurological conditions. Early recognition, correct diagnosis, and appropriate management of the condition are of vital importance to the prognosis, including reducing mortality rate, admissions to intensive care units, recurrence, complications of the disease and in some cases, irreversible hippocampal damage. We present a case that highlights the typical presentation of anti-NMDA receptor encephalitis in a young woman and discuss management and outcome.
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17
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Agarwal K, Manza P, Chapman M, Nawal N, Biesecker E, McPherson K, Dennis E, Johnson A, Volkow ND, Joseph PV. Inflammatory Markers in Substance Use and Mood Disorders: A Neuroimaging Perspective. Front Psychiatry 2022; 13:863734. [PMID: 35558424 PMCID: PMC9086785 DOI: 10.3389/fpsyt.2022.863734] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022] Open
Abstract
Chronic exposure to addictive drugs in substance use disorders and stressors in mood disorders render the brain more vulnerable to inflammation. Inflammation in the brain, or neuroinflammation, is characterized by gliosis, microglial activation, and sustained release of cytokines, chemokines, and pro-inflammatory factors compromising the permeability of the blood-brain barrier. There is increased curiosity in understanding how substance misuse and/or repeated stress exposure affect inflammation and contribute to abnormal neuronal activity, altered neuroplasticity, and impaired cognitive control, which eventually promote compulsive drug-use behaviors and worsen mood disorders. This review will emphasize human imaging studies to explore the link between brain function and peripheral markers of inflammation in substance use disorders and mood disorders.
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Affiliation(s)
- Khushbu Agarwal
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States.,Section of Sensory Science and Metabolism, Division of Intramural Research, U.S. Department of Health and Human Services, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Peter Manza
- Laboratory of Neuroimaging, Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Marquis Chapman
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Nafisa Nawal
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Erin Biesecker
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Katherine McPherson
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Evan Dennis
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Allison Johnson
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Nora D Volkow
- Laboratory of Neuroimaging, Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Paule V Joseph
- Section of Sensory Science and Metabolism Unit, Division of Intramural Research, Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States.,Section of Sensory Science and Metabolism, Division of Intramural Research, U.S. Department of Health and Human Services, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
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Wang J, Liu X, Lian J, Zheng H, Cai D, Cai H, Zhou D, Lin S, Kong F, Qin X, Bi J. Autoimmune antibodies in first-episode psychosis with red flags: A hospital-based case-control study protocol. Front Psychiatry 2022; 13:976159. [PMID: 36276313 PMCID: PMC9579361 DOI: 10.3389/fpsyt.2022.976159] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Research is increasingly identifying an overlap between psychosis and immunological dysregulation. Certain autoantibodies are being identified in a small but probably relevant subgroup of patients with psychosis. The term "autoimmune psychosis" (AIP) and its corresponding red-flag signs present the opportunity for a new field in psychiatry to promote diagnostic workup and immunomodulating therapy in individual cases. OBJECTIVES The present protocol aims to determine the seroprevalence of autoantibodies in first-episode psychosis (FEPs) using AIP red flag signs, and to explore the frequency of autoantibody subtypes and potential mediating confounders. METHODS/DESIGN This is a hospital-based case-control study. All participants will be consecutively selected from the main tertiary psychiatric hospital in Shenzhen City, China. Individuals admitted to the psychiatric ward and diagnosed with FEPs will be enrolled. Based on recent consensus, participants with red flags of AIPs will be defined as cases, while the remainder will be matched as controls. Seropositive antibodies will be detected and verified in cerebrospinal fluid (CSF) samples based on the fixed cell-based assay (CBA) method. The propensity score-adjusted odds ratios will be determined to investigate the key mediating confounders regarding autoantibody subtypes and red flag subsets. DISCUSSION The results of this study will facilitate the early identification of AIPs in FEP patients using the red flag sign and help identify key mediators that improve the accuracy of diagnostic algorithms. It will have clinical significance to focus on serum antibodies that have been verified in CSF samples, due to its consistency with clinical practices in current psychiatry.
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Affiliation(s)
- Jianjun Wang
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Global Clinical Scholars Research Training, Harvard Medical School, Boston, MA, United States
| | - Xuan Liu
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Jie Lian
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Haotao Zheng
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Dongbin Cai
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Haobin Cai
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Dan Zhou
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China.,Department of Laboratory Medicine, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Songjun Lin
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Fanxin Kong
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Xiude Qin
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.,The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Jianqiang Bi
- Department of Public Health, Shenzhen Kangning Hospital, Shenzhen Mental Health Center, Shenzhen, China
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Özbudak P, Erçelebi H, Gücüyener K. Psychosis: a rare onset symptom of pediatric multiple sclerosis. Neurocase 2021; 27:474-476. [PMID: 34927555 DOI: 10.1080/13554794.2021.2016859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neuropsychiatric symptoms are common in multiple sclerosis (MS), but it is rarely associated with psychosis as the initial manifestation. Fourteen-year-old boy admitted with auditory hallucinations. His neurological examination was normal. Brain magnetic resonance imaging (MRI) showed multiple demyelinating lesions in the mesencephalon and periventricular regions. His IgG index was high and the oligoclonal band was positive. MS was diagnosed and pulsed corticosteroids were given and his psychotic symptoms regressed. After 22months, the patient presented with hemi-hypoesthesia, and repeated MRI showed new contrast enhancing lesion detected. His complaints completely resolved with pulse corticosteroid therapy. Increasing morbidity due to delay in MS treatment underlines the need to consider MS in the differential diagnosis of pediatric cases presenting with psychosis.
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Affiliation(s)
- Pınar Özbudak
- Department of Pediatrics, Division of Child Neurology, Gazi University Medical School, Ankara, Turkey
| | - Hakan Erçelebi
- Department of Pediatrics, Division of Child Neurology, Gazi University Medical School, Ankara, Turkey
| | - Kıvılcım Gücüyener
- Department of Pediatrics, Division of Child Neurology, Gazi University Medical School, Ankara, Turkey
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20
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Bordonne M, Chawki MB, Doyen M, Kas A, Guedj E, Tyvaert L, Verger A. Brain 18F-FDG PET for the diagnosis of autoimmune encephalitis: a systematic review and a meta-analysis. Eur J Nucl Med Mol Imaging 2021; 48:3847-3858. [PMID: 33677643 DOI: 10.1007/s00259-021-05299-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/02/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To consolidate current understanding of detection sensitivity of brain 18F-FDG PET scans in the diagnosis of autoimmune encephalitis and to define specific metabolic imaging patterns for the most frequently occurring autoantibodies. METHODS A systematic and exhaustive search of data available in the literature was performed by querying the PubMed/MEDLINE and Cochrane databases for the search terms: ((PET) OR (positron emission tomography)) AND ((FDG) OR (fluorodeoxyglucose)) AND ((encephalitis) OR (brain inflammation)). Studies had to satisfy the following criteria: (i) include at least ten pediatric or adult patients suspected or diagnosed with autoimmune encephalitis according to the current recommendations, (ii) specifically present 18F-FDG PET and/or morphologic imaging findings. The diagnostic 18F-FDG PET detection sensitivity in autoimmune encephalitis was determined for all cases reported in this systematic review, according to a meta-analysis following the PRISMA method, and selected publication quality was assessed with the QUADAS-2 tool. RESULTS The search strategy identified 626 articles including references from publications. The detection sensitivity of 18F-FDG PET was 87% (80-92%) based on 21 publications and 444 patients included in the meta-analysis. We also report specific brain 18F-FDG PET imaging patterns for the main encephalitis autoantibody subtypes. CONCLUSION AND RELEVANCE Brain 18F-FDG PET has a high detection sensitivity and should be included in future diagnostic autoimmune encephalitis recommendations. Specific metabolic 18F-FDG PET patterns corresponding to the main autoimmune encephalitis autoantibody subtypes further enhance the value of this diagnostic.
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Affiliation(s)
- Manon Bordonne
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
| | - Mohammad B Chawki
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
| | - Matthieu Doyen
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France
- Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France
| | - Aurelie Kas
- Nuclear Medicine Department, Pitié-Salpêtrière Hospital, APHP Sorbonne-Université, Laboratoire d'Imagerie Biomédicale, Sorbonne Université, F-75000, Paris, France
| | - Eric Guedj
- Nuclear Medicine Department, Aix Marseille Univ, APHM, CNRS, Centrale Marseille, Institut Fresnel, Timone Hospital, CERIMED, F-13000, Marseille, France
| | - Louise Tyvaert
- Department of Neurology, Université de Lorraine, CRAN UMR 7039, CHRU, F-54000, Nancy, France
| | - Antoine Verger
- Department of Nuclear Medicine and Nancyclotep Imaging Platform, Université de Lorraine, CHRU Nancy, Rue du Morvan, 54500 Vandoeuvre-les-Nancy, F-54000, Nancy, France.
- Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France.
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21
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Abstract
Neuropsychiatric sequalae to coronavirus disease 2019 (COVID-19) infection are beginning to emerge, like previous Spanish influenza and severe acute respiratory syndrome episodes. Streptococcal infection in paediatric patients causing obsessive compulsive disorder (PANDAS) is another recent example of an infection-based psychiatric disorder. Inflammation associated with neuropsychiatric disorders has been previously reported but there is no standard clinical management approach established. Part of the reason is that it is unclear what factors determine the specific neuronal vulnerability and the efficacy of anti-inflammatory treatment in neuroinflammation. The emerging COVID-19 data suggested that in the acute stage, widespread neuronal damage appears to be the result of abnormal and overactive immune responses and cytokine storm is associated with poor prognosis. It is still too early to know if there are long-term-specific neuronal or brain regional damages associated with COVID-19, resulting in distinct neuropsychiatric disorders. In several major psychiatric disorders where neuroinflammation is present, patients with abnormal inflammatory markers may also experience less than favourable response or treatment resistance when standard treatment is used alone. Evidence regarding the benefits of co-administered anti-inflammatory agents such as COX-2 inhibitor is encouraging in selected patients though may not benefit others. Disease-modifying therapies are increasingly being applied to neuropsychiatric diseases characterised by abnormal or hyperreactive immune responses. Adjunct anti-inflammatory treatment may benefit selected patients and is definitely an important component of clinical management in the presence of neuroinflammation.
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22
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Weiss D, Kertzscher L, Degering M, Wozniak D, Kluge M. Anti-NMDA receptor encephalitis and overlapping demyelinating disorder in a 20-year old female with borderline personality disorder: proposal of a diagnostic and therapeutic algorithm for autoimmune encephalitis in psychiatric patients "case report". BMC Psychiatry 2021; 21:355. [PMID: 34266413 PMCID: PMC8280600 DOI: 10.1186/s12888-021-03269-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/09/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anti-NMDA receptor encephalitis (NMDAR-E) is an autoimmune encephalitis (AE) mainly affecting young females. It typically presents with isolated psychiatric symptoms (e.g. depressed mood) at first and neurological abnormalities (e.g. seizures, movement disorders) only develop later. Thus, there is a high risk of overlooking NMDAR-E in patients with preexisting psychiatric illness due to symptom overlap in the prodromal period of the disease when treatment is most effective. Although rare, concomitant or sequential development of a demyelinating disorder is increasingly recognized as an associated disease entity (overlap syndrome), with immediate diagnostic and therapeutic implications. CASE PRESENTATION We report a patient with a borderline personality disorder (BPD), which developed NMDAR-E and an overlapping demyelinating disorder with anti-Myelin oligodendrocyte glycoprotein (MOG) -IgG positivity. The initial clinical presentation with predominantly affective symptoms (e.g. mood lability, anxiety, depressed mood) lead us to suspect an exacerbation of the BPD at first. However, acute changes in premorbid behavior, newly developed psychotic symptoms and memory deficits lead us to the correct diagnosis of an AE, which was further complicated by the development of a demyelinating disorder. As a result of impaired illness awareness and psychosis, diagnostic and treatment was difficult to carry out. The symptoms completely remitted after treatment with methylprednisolone 1 g daily for 5 days and 5 cycles of plasma exchange. CONCLUSIONS Continuous awareness for neuropsychiatric clinical warning signs in patients with a pre-diagnosed psychiatric disorder is important for a timely diagnosis. Therefore, we believe that the diagnostic and therapeutic algorithm provided here, for the first time specifically addressing patients with preexisting psychiatric illness and integrating overlap syndromes, can be a useful tool. Moreover, in order to timely perform diagnostics and treatment, judicial approval should be obtained rapidly.
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Affiliation(s)
- David Weiss
- Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany. .,Department of Neurology, Rostock University Medical Center, Germany; Gehlsheimer Straße 20, 18147, Rostock, Germany.
| | - Lisa Kertzscher
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Magdalena Degering
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - David Wozniak
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Michael Kluge
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
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23
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Mechanisms of Drug Resistance in the Pathogenesis of Epilepsy: Role of Neuroinflammation. A Literature Review. Brain Sci 2021; 11:brainsci11050663. [PMID: 34069567 PMCID: PMC8161227 DOI: 10.3390/brainsci11050663] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is a chronic neurological disorder characterized by recurring spontaneous seizures. Drug resistance appears in 30% of patients and it can lead to premature death, brain damage or a reduced quality of life. The purpose of the study was to analyze the drug resistance mechanisms, especially neuroinflammation, in the epileptogenesis. The information bases of biomedical literature Scopus, PubMed, Google Scholar and SciVerse were used. To obtain full-text documents, electronic resources of PubMed Central and Research Gate were used. The article examines the recent research of the mechanisms of drug resistance in epilepsy and discusses the hypotheses of drug resistance development (genetic, epigenetic, target hypothesis, etc.). Drug-resistant epilepsy is associated with neuroinflammatory, autoimmune and neurodegenerative processes. Neuroinflammation causes immune, pathophysiological, biochemical and psychological consequences. Focal or systemic unregulated inflammatory processes lead to the formation of aberrant neural connections and hyperexcitable neural networks. Inflammatory mediators affect the endothelium of cerebral vessels, destroy contacts between endothelial cells and induce abnormal angiogenesis (the formation of “leaky” vessels), thereby affecting the blood–brain barrier permeability. Thus, the analysis of pro-inflammatory and other components of epileptogenesis can contribute to the further development of the therapeutic treatment of drug-resistant epilepsy.
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24
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Loureiro CM, Corsi-Zuelli F, Fachim HA, Shuhama R, Chagas NMDS, Menezes PR, Del-Ben CM, Louzada-Junior P. Plasma prevalence of anti-N-methyl-d-aspartate receptor IgG antibodies in early stages of psychosis. CIENCIA & SAUDE COLETIVA 2021; 26:1085-1094. [PMID: 33729361 DOI: 10.1590/1413-81232021263.07552019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/05/2019] [Indexed: 11/22/2022] Open
Abstract
We investigated the feasibility of including plasma anti-NMDAR antibody screening in the assessment of first-episode psychosis patients in an early intervention programme in the Southern hemisphere. Anti-NMDAR IgG antibodies were assessed by ELISA in 166 patients (64.0% men), 166 matched population-based controls and 76 patients' siblings (30.3% men). Fisher's exact test and ANOVA were performed. Positive anti-NMDAR antibody patients were more often observed in bipolar disorder (10.0%) than schizophrenia (2.4%) or psychotic depression (3.1%), although no significant differences were observed. Our results are not conclusive regarding the inclusion of plasma anti-NMDAR IgG antibodies in differential diagnostic protocols for psychosis.
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Affiliation(s)
- Camila Marcelino Loureiro
- Departamento de Medicina Interna, Divisão de Imunologia Clínica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). Av. Bandeirantes 3900, Monte Alegre. 14049-900 Ribeirão Preto SP Brasil.
| | - Fabiana Corsi-Zuelli
- Departamento de Neurociência e Comportamento, Divisão de Psiquiatria, Faculdade de Medicina de Ribeirão Preto, USP. Ribeirão Preto SP Brasil
| | - Helene Aparecida Fachim
- Departamento de Endocrinologia e Metabolismo, Salford Royal Foundation Trust. Salford Reino Unido
| | - Rosana Shuhama
- Departamento de Neurociência e Comportamento, Divisão de Psiquiatria, Faculdade de Medicina de Ribeirão Preto, USP. Ribeirão Preto SP Brasil
| | - Natália Mota de Souza Chagas
- Departamento de Neurociência e Comportamento, Divisão de Psiquiatria, Faculdade de Medicina de Ribeirão Preto, USP. Ribeirão Preto SP Brasil
| | - Paulo Rossi Menezes
- Departamento de Medicina Preventiva, Faculdade de Medicina, USP. São Paulo SP Brasil
| | - Cristina Marta Del-Ben
- Departamento de Neurociência e Comportamento, Divisão de Psiquiatria, Faculdade de Medicina de Ribeirão Preto, USP. Ribeirão Preto SP Brasil
| | - Paulo Louzada-Junior
- Departamento de Medicina Interna, Divisão de Imunologia Clínica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). Av. Bandeirantes 3900, Monte Alegre. 14049-900 Ribeirão Preto SP Brasil.
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25
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Abe K, Chiba Y, Katsuse O, Takahashi Y, Suda A, Hattori S, Yoshimi R, Kirino Y, Kunii M, Yoshimi A, Asami T, Hishimoto A. Exploratory investigation on antibodies to GluN1 and cognitive dysfunction in patients with chronic autoimmune psychosis. Neurosci Lett 2020; 743:135588. [PMID: 33359543 DOI: 10.1016/j.neulet.2020.135588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/14/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Mild cognitive dysfunction has been implicated in a number of psychiatric diseases and affects social functioning. Although clinical criteria were recently proposed for autoimmune psychosis (AP), biomarkers have not yet been established for the severity and prognosis of cognitive dysfunction. We herein investigated the relationships between 3 types of serum antibodies and cognitive dysfunction in chronic psychiatric patients suspected of AP. METHODS We included 31 patients suspected of AP and obtained information on their clinical characteristics. Three types of autoantibodies (the anti-N-methyl-D-aspartate receptor (anti-NMDAR Ab), anti-N-terminal of GluN1 (anti-GluN1-NT Ab), and anti-thyroid antibodies) were evaluated in serum. Cognitive function was assessed using Wechsler Adult Intelligence Scale-III. We examined the relationships between serum autoantibodies and cognitive dysfunction in patients using multiple regression models. RESULTS Serum titers of anti-GluN1-NT Ab significantly contributed to the estimated score of working memory (B= -55.85, β= -0.46, p= 0.01), while no correlation was observed between the other 2 types of antibodies and cognitive function. CONCLUSIONS The present results indicate the potential of serum anti-GluN1-NT Ab as a biomarker for the severity and prognosis of cognitive dysfunction underlying various psychiatric symptoms in patients with AP. The pathological significance of anti-GluN1-NT Ab needs to be verified in future studies.
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Affiliation(s)
- Kie Abe
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yuhei Chiba
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Omi Katsuse
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan; Yokohama Hoyu Hospital 644 Kanegaya, Asahi-ku, Yokohama, 241-0812, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders 886 Urushiyama, Aoi-ku, Shizuoka, 420-8688, Japan
| | - Akira Suda
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Saki Hattori
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Misako Kunii
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Asuka Yoshimi
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takeshi Asami
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Akitoyo Hishimoto
- Department of Psychiatry, Yokohama City University Graduate School of Medicine 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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26
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Association of thyroid peroxidase antibodies with anti-neuronal surface antibodies in health, depression and schizophrenia - Complementary linkage with somatic symptoms of major depression. Brain Behav Immun 2020; 90:47-54. [PMID: 32750542 DOI: 10.1016/j.bbi.2020.07.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 12/25/2022] Open
Abstract
Hashimoto's thyroiditis has been associated with major depression (MD) and schizophrenia (Sz) in epidemiological studies. However, diagnostically relevant antibodies (Abs) against thyroid peroxidase (TPO) and thyroglobulin (Tg) do not act directly on neurons. We hypothesized that an increased prevalence of anti-brain-Abs in thyroid-Ab-carriers could be linked with MD and Sz even without clinically manifest Hashimoto's thyroiditis. Serum samples from 638 acutely-ill patients with MD, Sz or matched controls were systematically screened for TPO- and Tg-Abs, other endocrine-Abs and a spectrum of specific anti-brain-Abs (directed against neuronal cell surface, synaptic, other neuronal or glial proteins). Analyses were based on indirect immunofluorescence in biochip mosaics of frozen tissue sections and transfected HEK293 cells expressing respective recombinant target antigens. Psychopathology was assessed on admission and after 6 weeks treatment by HAMD-21 (in MD) or PANSS (in Sz). Seroprevalence of TPO- and/or Tg-Abs was comparable in ill and healthy individuals (MD ~10%, Sz ~7%, controls ~9%) but thyroid-Abs were associated with neuronal cell surface/synaptic-Abs (p = 0.005), particularly in schizophrenia. Thyroid Ab-positive MD patients showed higher HAMD-21 scores (particularly somatic symptoms) at baseline (p = 0.026) and better reduction of symptoms after 6 weeks (p = 0.049) than thyroid-Ab-negative patients. This was unrelated to antidepressant drug dosage, thyroid hormonal-, inflammation- and anti-brain-Ab-status. No link with PANSS scores was observed in Sz. In conclusion, the co-occurrence of thyroid-Abs and neuronal surface/synaptic-Abs may be associated with Sz. Future cerebrospinal fluid research may be promising to clarify if thyroid-Ab-associated neuronal-Abs reach the brain in Sz patients. Thyroid-Ab-related differences regarding disease-severity and -course in MD are currently unexplained, but may be caused by un-identified anti-brain-Abs or a direct action of TPO-Abs on astrocytes.
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27
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Alessi MG, Bennett JM. Mental health is the health of the whole body: How psychoneuroimmunology & health psychology can inform & improve treatment. J Eval Clin Pract 2020; 26:1539-1547. [PMID: 32171052 DOI: 10.1111/jep.13386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/12/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Converging and accumulating evidence for the cross-communication among the nervous, immune, and endocrine systems, a field of study known as psychoneuroimmunology, implicates immunological dysfunction as a shared and common mechanism of both mental and physical illness. For example, psychiatric disorders like schizophrenia, bipolar disorder, major depression, and anxiety disorders have higher prevalence rates across a spectrum of autoimmune conditions compared to the general population. Additionally, subclinical immunological abnormalities are observed in a variety of psychiatric conditions, with chronic inflammation most extensively studied in the pathophysiology of depression. These observations blur the historical distinctions between mental and physical illness, yet clinical practice remains fragmented and primarily focused on differentially treating individual symptoms. PROPOSED THESIS Therapeutically targeting inflammation offers translational opportunities for integrating mental and physical healthcare, a key niche of the interdisciplinary field of health psychology. CONCLUSION Utilizing a psychoneuroimmunological lens, health psychologists and clinicians can reconceptualize healthcare through integrative treatment approaches and advocacy for comprehensive policy-level reform at both the individual-level of care as well as community-wide prevention approaches.
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Affiliation(s)
- Maria G Alessi
- Health Psychology PhD Program, UNC Charlotte, Charlotte, North Carolina, USA
| | - Jeanette M Bennett
- Health Psychology PhD Program, UNC Charlotte, Charlotte, North Carolina, USA.,Department of Psychological Science, UNC Charlotte, Charlotte, North Carolina, USA
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28
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Bechter K. The Challenge of Assessing Mild Neuroinflammation in Severe Mental Disorders. Front Psychiatry 2020; 11:773. [PMID: 32973573 PMCID: PMC7469926 DOI: 10.3389/fpsyt.2020.00773] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
Recent psychoneuroimmunology research has provided new insight into the etiology and pathogenesis of severe mental disorders (SMDs). The mild encephalitis (ME) hypothesis was developed with the example of human Borna disease virus infection years ago and proposed, that a subgroup SMD patients, mainly from the broad schizophrenic and affective spectrum, could suffer from mild neuroinflammation, which remained undetected because hard to diagnose with available diagnostic methods. Recently, in neurology an emerging new subgroup of autoimmune encephalitis (AE) cases suffering from various neurological syndromes was described in context with the discovery of an emerging list of Central Nervous System (CNS) autoantibodies. Similarly in psychiatry, consensus criteria of autoimmune psychosis (AP) were developed for patients presenting with CNS autoantibodies together with isolated psychiatric symptoms and paraclinical findings of (mild) neuroinflammation, which in fact match also the previously proposed ME criteria. Nevertheless, identifying mild neuroinflammation in vivo in the individual SMD case remains still a major clinical challenge and the possibility that further cases of ME remain still under diagnosed appears an plausible possibility. In this paper a critical review of recent developments and remaining challenges in the research and clinical diagnosis of mild neuroinflammation in SMDs and in general and in transdisciplinary perspective to psycho-neuro-immunology and neuropsychiatry is given. Present nosological classifications of neuroinflammatory disorders are reconsidered with regard to findings from experimental and clinical research. A refined grading list of clinical states including "classical" encephalitis, AE, AP/ME,and newly proposed terms like parainflammation, stress-induced parainflammation and neuroprogression, and their respective relation to neurodegeneration is presented, which may be useful for further research on the possible causative role of mild neuroinflammation in SMDs. Beyond, an etiology-focused subclassification of ME subtypes, like autoimmune ME or infectious ME, appears to be required for differential diagnosis and individualized treatment. The present status of the clinical diagnosis of mild neuroinflammatory mechanisms involved in SMDs is outlined with the example of actual diagnosis and therapy in AP. Ideas for future research to unravel the contribution of mild neuroinflammation in the causality of SMDs and the difficulties expected to come to novel immune modulatory, anti-infectious or anti-inflammatory therapeutic principles in the sense of precision medicine are discussed.
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Affiliation(s)
- Karl Bechter
- Department for Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Endres D, Prüss H, Dressing A, Schneider J, Feige B, Schweizer T, Venhoff N, Nickel K, Meixensberger S, Matysik M, Maier SJ, Domschke K, Urbach H, Meyer PT, Tebartz van Elst L. Psychiatric Manifestation of Anti-LGI1 Encephalitis. Brain Sci 2020; 10:brainsci10060375. [PMID: 32560097 PMCID: PMC7348933 DOI: 10.3390/brainsci10060375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is typically characterized by limbic encephalitis, faciobrachial dystonic seizures and hyponatremia. The frequency with which milder forms of anti-LGI1 encephalitis mimic isolated psychiatric syndromes, such as psychoses, or may lead to dementia if untreated, is largely unknown. Case presentation: Here, the authors present a 50-year-old patient who had suffered from neurocognitive deficits and predominant delusions for over one and a half years. He reported a pronounced feeling of thirst, although he was drinking 10–20 liters of water each day, and he was absolutely convinced that he would die of thirst. Due to insomnia in the last five years, the patient took Z-drugs; later, he also abused alcohol. Two years prior to admission, he developed a status epilepticus which had been interpreted as a withdrawal seizure. In his serum, anti-LGI1 antibodies were repeatedly detected by different independent laboratories. Cerebrospinal fluid analyses revealed slightly increased white blood cell counts and evidence for blood–brain-barrier dysfunction. Magnetic resonance imaging showed hyperintensities mesio-temporally and in the right amygdala. In addition, there was a slight grey–white matter blurring. A cerebral [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) examination of his brain showed moderate hypometabolism of the bilateral rostral mesial to medial frontal cortices. Treatment attempts with various psychotropic drugs remained unsuccessful in terms of symptom relief. After the diagnosis of probable chronified anti-LGI1 encephalitis was made, two glucocorticoid pulse treatments were performed, which led to a slight improvement of mood and neurocognitive deficits. Further therapy was not desired by the patient and his legally authorized parents. Conclusion: This case study describes a patient with anti-LGI1 encephalitis in the chronified stage and a predominant long-lasting psychiatric course with atypical symptoms of psychosis and typical neurocognitive deficits. The patient’s poor response to anti-inflammatory drugs was probably due to the delayed start of treatment. This delay in diagnosis and treatment may also have led to the FDG-PET findings, which were compatible with frontotemporal dementia (“state of damage”). In similar future cases, newly occurring epileptic seizures associated with psychiatric symptoms should trigger investigations for possible autoimmune encephalitis, even in patients with addiction or other pre-existing psychiatric conditions. This should in turn result in rapid organic clarification and—in positive cases—to anti-inflammatory treatment. Early treatment of anti-LGI1 encephalitis during the “inflammatory activity state” is crucial for overall prognosis and may avoid the development of dementia in some cases. Based on this case, the authors advocate the concept—long established in many chronic inflammatory diseases in rheumatology—of distinguishing between an “acute inflammatory state” and a “state of organ damage” in autoimmune psychosis resembling neurodegenerative mechanisms.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Correspondence: ; Tel.: +49-761-270-66360; Fax: +49-761-270-69390
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany;
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany
| | - Andrea Dressing
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Johanna Schneider
- Renal Division, Department of Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Tina Schweizer
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Sophie Meixensberger
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Miriam Matysik
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Simon J. Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
- Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Philipp T. Meyer
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (B.F.); (K.N.); (S.M.); (M.M.); (S.J.M.); (L.T.v.E.)
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany; (T.S.); (K.D.)
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Chernyshkova I, Estefan B, Hoque MR, Lee A. Neurologic Presentation of Probable Seronegative Paraneoplastic Encephalitis in a Woman With an Ovarian Teratoma. Cureus 2020; 12:e8485. [PMID: 32656003 PMCID: PMC7341459 DOI: 10.7759/cureus.8485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/06/2020] [Indexed: 12/24/2022] Open
Abstract
We describe a case of probable autoimmune encephalitis developed as a result of paraneoplastic syndrome in a woman with an ovarian teratoma. Patients may present with psychiatric and neurological symptoms, which are caused by anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies produced in response to a teratoma that crosses the blood-brain barrier and damages brain tissue in the limbic area, causing encephalitis. Our patient presented with seizures, myoclonus, and memory problems. This is a relatively newly discovered and rare problem; however, it can be quite debilitating if left untreated. This diagnosis may be often missed due to the absence of highly sensitive tests. Autoimmune encephalitis has to be on the list of differential diagnoses for patients with new-onset psychiatric or neurological symptoms.
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Affiliation(s)
| | - Bebsy Estefan
- Psychiatry, St. Barnabas Medical Center, Bronx, USA
- Psychiatry, NewYork-Presbyterian/Weill Cornell Medical Center, Manhattan, USA
| | - Md Rezaul Hoque
- Internal Medicine, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Alice Lee
- Internal Medicine, City University of New York School of Medicine, Bronx, USA
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de Sousa Arantes Ferreira G, Conde Watanabe AL, de Carvalho Trevizoli N, Felippe Jorge FM, Ferreira Figueira AV, de Fatima Couto C, Viana de Lima L, Liduario Raupp DR. Tacrolimus-Associated Psychotic Disorder: A Report of 2 Cases. Transplant Proc 2020; 52:1350-1353. [PMID: 32197865 DOI: 10.1016/j.transproceed.2020.01.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
Abstract
Psychotic disorders are a group of psychiatric disorders characterized by the presence of delusions, hallucinations, bizarre behavior, and disorganized speech. There are several possible causes for the occurrence of psychotic disorders in patients who underwent solid organ transplant, including pre-existing mental illness, electrolyte disturbances, infections of the central nervous system, and adverse reaction to drugs. Calcineurin inhibitors are a class of immunosuppressive drugs, such as tacrolimus and cyclosporine, that are currently considered the mainstay in the immunosuppressive drug regimen of patients who underwent solid organ transplant. Neurotoxicity is one of the adverse reactions associated with the use of calcineurin inhibitors, ranging from upper limb tremors to psychotic disorders and seizures. We report the cases of 2 liver transplant recipients who developed severe psychotic disorder 1 month after the procedure. After an extensive investigation for other possible triggers of psychiatric disease, the use of tacrolimus was considered to be the most likely cause for the acute psychotic disorder. In less than 24 hours after suspension of that drug, all symptoms disappeared in both patients, making a causal relationship with tacrolimus even more likely. The patients were then given cyclosporine, another drug from the same class, allowing for adequate immunosuppression and preserved graft function, with no further psychiatric symptoms. This report confirms that a 24-hour trial of tacrolimus suspension can be safe and effective in the diagnosis of drug-related psychotic disorders in patients who underwent liver transplant. This article is compliant with the Helsinki Congress and the Istanbul Declaration.
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Lavasani S, Lipsitt A, Young KA, Bourgeois JA. Psychiatric Presentation of Probable Seronegative Autoimmune Encephalitis in a Late Middle-Aged Woman With Ovarian Teratoma. PSYCHOSOMATICS 2020; 61:288-295. [DOI: 10.1016/j.psym.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022]
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Cellular mechanisms and molecular signaling pathways in stress-induced anxiety, depression, and blood-brain barrier inflammation and leakage. Inflammopharmacology 2020; 28:643-665. [PMID: 32333258 DOI: 10.1007/s10787-020-00712-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/15/2020] [Indexed: 12/17/2022]
Abstract
Depression and anxiety are comorbid conditions in many neurological or psychopathological disorders. Stress is an underlying event that triggers development of anxiety and depressive-like behaviors. Recent experimental data indicate that anxiety and depressive-like behaviors occurring as a result of stressful situations can cause blood-brain barrier (BBB) dysfunction, which is characterized by inflammation and leakage. However, the underlying mechanisms are not completely understood. This paper sought to review recent experimental preclinical and clinical data that suggest possible molecular mechanisms involved in development of stress-induced anxiety and depression with associated BBB inflammation and leakage. Critical therapeutic targets and potential pharmacological candidates for treatment of stress-induced anxiety and depression with associated BBB dysfunctions are also discussed.
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Steiner J, Prüss H, Köhler S, Frodl T, Hasan A, Falkai P. Autoimmune encephalitis with psychosis: Warning signs, step-by-step diagnostics and treatment. World J Biol Psychiatry 2020; 21:241-254. [PMID: 30513253 DOI: 10.1080/15622975.2018.1555376] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives: Despite intensive research, schizophrenia and schizoaffective disorders continue to be theoretical constructs that describe clinical syndromes and no pathophysiologically defined diseases. Moreover, there are no clear biomarkers at hand. Therefore, these diagnoses are still set up based on clinical ICD-10/DSM-5 criteria and the exclusion of alcohol-/drug-associated, systemic or other brain organic causes.Methods: Recently, autoimmune encephalitis with psychotic symptoms caused by specific antineuronal antibodies has been identified as a rare, but potentially treatable differential diagnosis. However, these inflammatory brain diseases are not reliably detected by our current routine diagnostic workup in psychiatry. This qualitative review provides structured diagnostic and therapeutic support for clinical practice.Results: Disturbances of consciousness and orientation, catatonia, speech dysfunction, focal neurological signs, epileptic seizures/EEG abnormalities or autonomic dysfunction are warning signs in psychiatric patients which should always induce cerebrospinal fluid analysis with determination of antineuronal autoantibodies. Currently established immunotherapy strategies are summarised, taking into account international expert advice.Conclusions: Guided by clinical warning signs, our qualitative review enables rapid and reliable diagnosis of definite autoimmune encephalitis. This is of high relevance for the affected individuals, since early and sufficiently intense immunotherapy often leads to a good prognosis despite severe illness.
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Affiliation(s)
- Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin and Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Köhler
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
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35
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Neuroinflammation in CNS diseases: Molecular mechanisms and the therapeutic potential of plant derived bioactive molecules. PHARMANUTRITION 2020. [DOI: 10.1016/j.phanu.2020.100176] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Endres D, Rauer S, Pschibul A, Süß P, Venhoff N, Runge K, Feige B, Denzel D, Nickel K, Schweizer T, Maier S, Egger K, Domschke K, Meyer PT, Prüss H, Tebartz van Elst L. Novel Antineuronal Autoantibodies With Somatodendritic Staining Pattern in a Patient With Autoimmune Psychosis. Front Psychiatry 2020; 11:627. [PMID: 32848899 PMCID: PMC7424063 DOI: 10.3389/fpsyt.2020.00627] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 06/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Autoimmune encephalitis, such as anti-NMDA-receptor encephalitis, typically presenting with subacute onset of neuropsychiatric symptoms, can be detected by antineuronal autoantibodies or inflammatory changes in the cerebrospinal fluid (CSF), as well as pathological alterations in electroencephalography (EEG), magnetic resonance imaging (MRI), or [18F]fluorodeoxyglucose positron emission tomography (FDG PET). For patients with predominant psychotic symptoms, the term autoimmune psychosis was proposed. Here, the authors present the case of a patient with probable autoimmune psychosis associated with unknown antineuronal antibodies. CASE PRESENTATION A 18-year-old male patient with preexisting autism spectrum disorder developed a severe catatonic syndrome over 2.5 years. The MRI showed normal findings, the EEG depicted intermittent slowing, and the independent component analyses showed additional sharp spikes. However, FDG PET, the basic laboratory analysis and testing of the serum/CSF for well-characterized antineuronal autoantibodies were unsuspicious. The serum and CSF "tissue-based assay" using indirect immunofluorescence on unfixed murine brain tissue revealed antineuronal autoantibodies against an unknown epitope in granule cells in the cerebellum and to neurites of hippocampal interneurons with a somatodendritic staining pattern. The immunosuppressive treatment with high-dose glucocorticoids, plasma exchange, and rituximab led to partial improvement. CONCLUSION The patient probably suffered from autoantibody-associated autoimmune psychosis. The special features of the case were that the patient (1) presented with mostly inconspicuous basic diagnostics, except for the altered EEG in combination with the detection of CSF autoantibodies directed against a currently unknown epitope, (2) experienced an isolated and long-lasting psychotic course, and (3) had pre-existing autism spectrum disorder. The detection of a probable autoimmune pathophysiology in such cases seems important, as it offers new and more causal immunosuppressive treatment alternatives.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Pschibul
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick Süß
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kimon Runge
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Denzel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tina Schweizer
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Autoimmune encephalitis as a differential diagnosis of schizophreniform psychosis: clinical symptomatology, pathophysiology, diagnostic approach, and therapeutic considerations. Eur Arch Psychiatry Clin Neurosci 2020; 270:803-818. [PMID: 32166503 PMCID: PMC7474714 DOI: 10.1007/s00406-020-01113-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/08/2020] [Indexed: 12/12/2022]
Abstract
Primary schizophreniform psychoses are thought to be caused by complex gene-environment interactions. Secondary forms are based on a clearly identifiable organic cause, in terms of either an etiological or a relevant pathogenetic factor. The secondary or "symptomatic" forms of psychosis have reentered the focus stimulated by the discovery of autoantibody (Ab)-associated autoimmune encephalitides (AEs), such as anti-NMDA-R encephalitis, which can at least initially mimic variants of primary psychosis. These newly described secondary, immune-mediated schizophreniform psychoses typically present with the acute onset of polymorphic psychotic symptoms. Over the course of the disease, other neurological phenomena, such as epileptic seizures, movement disorders, or reduced levels of consciousness, usually arise. Typical clinical signs for AEs are the acute onset of paranoid hallucinatory symptoms, atypical polymorphic presentation, psychotic episodes in the context of previous AE, and additional neurological and medical symptoms such as catatonia, seizure, dyskinesia, and autonomic instability. Predominant psychotic courses of AEs have also been described casuistically. The term autoimmune psychosis (AP) was recently suggested for these patients. Paraclinical alterations that can be observed in patients with AE/AP are inflammatory cerebrospinal fluid (CSF) pathologies, focal or generalized electroencephalographic slowing or epileptic activity, and/or suspicious "encephalitic" imaging findings. The antibody analyses in these patients include the testing of the most frequently found Abs against cell surface antigens (NMDA-R, CASPR2, LGI1, AMPA-R, GABAB-R), intracellular antigens (Hu, Ri, Yo, CV2/CRMP5, Ma2 [Ta], amphiphysin, GAD65), thyroid antigens (TG, TPO), and antinuclear Abs (ANA). Less frequent antineuronal Abs (e.g., against DPPX, GABAA-R, glycine-R, IgLON5) can be investigated in the second step when first step screening is negative and/or some specific clinical factors prevail. Beyond, tissue-based assays on brain slices of rodents may detect previously unknown antineuronal Abs in some cases. The detection of clinical and/or paraclinical pathologies (e.g., pleocytosis in CSF) in combination with antineuronal Abs and the exclusion of alternative causes may lead to the diagnosis of AE/AP and enable more causal therapeutic immunomodulatory opportunities.
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Pollak TA, Lennox BR, Müller S, Benros ME, Prüss H, Tebartz van Elst L, Klein H, Steiner J, Frodl T, Bogerts B, Tian L, Groc L, Hasan A, Baune BT, Endres D, Haroon E, Yolken R, Benedetti F, Halaris A, Meyer JH, Stassen H, Leboyer M, Fuchs D, Otto M, Brown DA, Vincent A, Najjar S, Bechter K. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry 2020; 7:93-108. [PMID: 31669058 DOI: 10.1016/s2215-0366(19)30290-1] [Citation(s) in RCA: 203] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
Abstract
There is increasing recognition in the neurological and psychiatric literature of patients with so-called isolated psychotic presentations (ie, with no, or minimal, neurological features) who have tested positive for neuronal autoantibodies (principally N-methyl-D-aspartate receptor antibodies) and who have responded to immunotherapies. Although these individuals are sometimes described as having atypical, mild, or attenuated forms of autoimmune encephalitis, some authors feel that that these cases are sufficiently different from typical autoimmune encephalitis to establish a new category of so-called autoimmune psychosis. We briefly review the background, discuss the existing evidence for a form of autoimmune psychosis, and propose a novel, conservative approach to the recognition of possible, probable, and definite autoimmune psychoses for use in psychiatric practice. We also outline the investigations required and the appropriate therapeutic approaches, both psychiatric and immunological, for probable and definite cases of autoimmune psychoses, and discuss the ethical issues posed by this challenging diagnostic category.
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Affiliation(s)
- Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Belinda R Lennox
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Sabine Müller
- Department of Psychiatry and Psychotherapy Charité Campus Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael E Benros
- Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Harald Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases, CharitéCrossOver, Berlin, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hans Klein
- Department of Assertive Community Treatment, Lentis Mental Health Institute, Leek, Netherlands; Department of Assertive Community Treatment, VNN Addiction Care Institute, Groningen, Netherlands; Medical Imaging Centre, University of Groningen, Groningen, Netherlands
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Bernhard Bogerts
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Li Tian
- Psychiatry Research Centre, Beijing Huilongguan Hospital, Peking University, Beijing, China; Department of Physiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Laurent Groc
- Interdisciplinary Institute for NeuroSciences, Université de Bordeaux, Bordeaux, France
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Bernhard T Baune
- Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia; The Florey Institute of Mental Health and Neurosciences, The University of Melbourne, Parkville, VIC, Australia; Department of Psychiatry, University of Münster, Münster, Germany
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ebrahim Haroon
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert Yolken
- Department of Pediatrics, Stanley Neurovirology Division, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Francesco Benedetti
- Psychiatry and Clinical Psychobiology, Division of Neuroscience, Scientific Institute Ospedale San Raffaele, Milano, Italy; University Vita-Salute San Raffaele, Milano, Italy
| | - Angelos Halaris
- Department of Psychiatry, Loyola University Medical Center, Maywood, IL, USA
| | - Jeffrey H Meyer
- Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Institute of Medical Science, Toronto, ON, Canada; Departments of Psychiatry and Department of Pharmacology and Toxicology, Institute of Medical Science, Toronto, ON, Canada
| | - Hans Stassen
- Institute for Response-Genetics, Psychiatric University Hospital, Zurich, Switzerland
| | - Marion Leboyer
- Inserm U955, Fondation FondaMental, Department of Psychiatry and Addiction, Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Markus Otto
- Department of Neurology, University Clinic, Ulm University, Ulm, Germany
| | - David A Brown
- Department of Immunopathology and Department Clinical Immunology, New South Wales Health Pathology, Institute for Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Souhel Najjar
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Karl Bechter
- Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Colijn MA, Ismail Z. Clinically Relevant Anti-Neuronal Cell Surface Antibodies in Schizophrenia Spectrum Disorders. Neuropsychobiology 2019; 78:70-78. [PMID: 31096226 DOI: 10.1159/000499714] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/19/2019] [Indexed: 11/19/2022]
Abstract
Schizophrenia is a phenotypically heterogeneous and poorly understood disorder. While its etiology is likely multifactorial, immune system dysfunction has increasingly been implicated in its development. As hallucinations and delusions occur frequently and prominently in autoimmune encephalitis (AE), numerous studies have sought to determine whether a small subset of individuals diagnosed with schizophrenia possess anti-neuronal antibodies implicated in AE. Exploring this possibility is of clinical relevance, as identifying individuals with AE who have been misdiagnosed as having a primary psychotic disorder may allow for the implementation of appropriate immune-related therapies as early as possible in the course of the illness, in order to optimize outcomes, reduce illness chronicity, and minimize adverse events. This qualitative review serves to provide an overview of the existing literature on this topic, as well as to update previously published reviews. Although there is some evidence to suggest that in rare cases AE may be misdiagnosed as a primary psychotic disorder, particularly early in the course of the illness, numerous methodological differences between studies likely account for the highly variable findings, and interpretation of the results is particularly limited by a paucity of cerebrospinal fluid data. Moreover, the prevalence of misdiagnosis in chronic and treatment-resistant populations remains understudied. This is particularly problematic, as treatment resistance may represent an enriched population with respect to the presence of anti-neuronal antibodies, and given that such patients have few evidence-based treatment options available to them beyond clozapine.
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Affiliation(s)
| | - Zahinoor Ismail
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental HealthResearch and Education, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University ofCalgary, Calgary, Alberta, Canada
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Behrman S, Lennox B. Autoimmune encephalitis in the elderly: who to test and what to test for. EVIDENCE-BASED MENTAL HEALTH 2019; 22:172-176. [PMID: 31537612 PMCID: PMC10231602 DOI: 10.1136/ebmental-2019-300110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 02/03/2023]
Abstract
The awareness and understanding of autoimmune encephalitis are blossoming in neurology, and patients are being diagnosed and successfully treated with immunotherapy. The diverse symptomatology associated with autoimmune encephalitis means that patients may present initially to mental health services, which are, as yet, less well equipped to identify and investigate such phenomena. Older adult mental health services are used to managing complexity, but the range of pathologies presenting with unusual symptoms that may mimic autoimmune encephalitis is wide and there is no clear guidance as to when and how to investigate for possible autoimmune encephalitis. This paper examines the evidence supporting investigation and management strategies for patients with possible autoimmune encephalitis presenting to older adult psychiatrists.
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Endres D, Bechter K, Prüss H, Hasan A, Steiner J, Leypoldt F, Tebartz van Elst L. [Autoantibody-associated schizophreniform psychoses: clinical symptomatology]. DER NERVENARZT 2019; 90:547-563. [PMID: 30968197 DOI: 10.1007/s00115-019-0700-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
According to present concepts, primary psychotic disorders in the schizophrenia spectrum are probably caused by a complex interaction between multigenetic vulnerability and causally relevant environmental factors. In contrast, secondary psychotic disorders are the result of likely identifiable organic factors either in terms of a first causation (etiology) or a secondary cause (pathogenesis). In this context, autoantibody(ab)-associated autoimmune encephalitis (AE) plays an increasingly important role. Within the group of ab-associated AE with neuropsychiatric symptoms, anti-N-methyl-D-aspartate receptor encephalitis is the most prevalent one. Psychopathologically, polymorphic psychotic symptoms are often observed at onset of AE; however, over the course of this condition or even initially other neuropsychiatric phenomena are also common. The ill-defined entity of a steroid-responsive encephalopathy with thyroid antibodies (Hashimoto's encephalitis) is a heterogeneous syndrome that may also comprise isolated psychotic disorders presenting as classical schizophrenia.
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Affiliation(s)
- Dominique Endres
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland
| | - Karl Bechter
- Klinik für Psychiatrie und Psychotherapie II, Bezirkskrankenhaus Günzburg, Universität Ulm, Günzburg, Deutschland
| | - Harald Prüss
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Berlin, Berlin, Deutschland.,Experimentelle Neurologie und Klinik und Poliklinik für Neurologie, Charité Universitätsmedizin, Berlin, Deutschland
| | - Alkomiet Hasan
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum der Universität München, LMU, München, Deutschland
| | - Johann Steiner
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
| | - Frank Leypoldt
- Institut für Klinische Chemie und Klinik, Universitätsklinik Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - Ludger Tebartz van Elst
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland.
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Aneja J, Mahal P, Sudhakar G, Panda S, Tiwari S. Steroid-responsive Encephalopathy as a Semblance of Neuroleptic Malignant Syndrome in a Patient with Schizophrenia. Indian J Psychol Med 2019; 41:487-491. [PMID: 31548776 PMCID: PMC6753705 DOI: 10.4103/ijpsym.ijpsym_307_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jitender Aneja
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pankaj Mahal
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gautam Sudhakar
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Samhita Panda
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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43
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Iizuka T. [Recent progress in autoimmune encephalitis and its related disorders]. Rinsho Shinkeigaku 2019; 59:491-501. [PMID: 31341132 DOI: 10.5692/clinicalneurol.cn-001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
After the discovery of a series of autoantibodies against neuronal cell surface antigens (NSAs) of the CNS in the past 10 years, the concept of encephalitis has changed dramatically. Accordingly, a practical, syndrome-based diagnostic approach to autoimmune encephalitis was proposed in 2016. These autoantibodies have also been identified in a subset of overlapping encephalitis and demyelinating syndrome, epilepsy, first episode psychosis, movement disorders, post-herpes simplex encephalitis, progressive dementia, postpartum psychosis, stiff-person spectrum disorders, or non-REM/REM sleep behavior disorder. Although not all neuronal antibody tests are available in Japan, we have entered a new era that we have to make a correct diagnosis and start appropriate immunotherapy based on initial neurological assessment and conventional tests, without being constrained by conventional fixed ideas or normal-appearing brain MRIs while waiting for neuronal antibody test results. Although many issues need to be resolved in Japan in terms of diagnosis and treatment in autoimmune encephalitis, this review focusses on recent progress in autoimmune encephalitis and its related disorders closely related to clinical practice, including Hashimoto encephalopathy and new-onset refractory status epilepticus (NORSE).
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine
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44
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Steiner J, Prüß H, Köhler S, Hasan A, Falkai P. [Autoimmune encephalitis with psychotic symptoms : Diagnostics, warning signs and practical approach]. DER NERVENARZT 2019. [PMID: 29523913 DOI: 10.1007/s00115-018-0499-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Despite intensive research, a precise cause of schizophrenic and schizoaffective disorders has not yet been identified. Therefore, psychiatric diagnoses are still made based on clinical ICD-10/DSM‑5 criteria and not on any objective markers; however, various causes or pathophysiological processes may ultimately lead to similar symptoms. An important task for the future of psychiatry is to identify disease subtypes with a distinct pathophysiology to develop more specific and causally acting therapies. A new diagnostic entity has become established in clinical neurology and psychiatry in recent years: autoimmune encephalitis with psychotic symptoms caused by specific antineuronal antibodies has been identified as a rare but potentially treatable cause of psychotic disorders; however, these inflammatory brain diseases are not reliably detected by routine psychiatric diagnostics. Therefore, this qualitative review is intended to provide structured support for clinical practice, which, guided by clinical warning signals, enables a rapid and reliable diagnosis as well as the initiation of immunotherapy. In the case of psychiatric symptoms, the additional onset of focal neurological signs, disturbances of consciousness and orientation, autonomic instability or epileptic seizures and electroencephalograph (EEG) abnormalities should always be followed by a more specific cerebrospinal fluid analysis with determination of antineuronal autoantibodies. Although the scientific evidence indicates that only a small subgroup of patients is affected, the swift and correct diagnosis is of high therapeutic and prognostic relevance for the affected individuals.
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Affiliation(s)
- J Steiner
- Klinik für Psychiatrie und Psychotherapie, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland. .,Center for Behavioral Brain Sciences, Magdeburg, Deutschland.
| | - H Prüß
- Experimentelle Neurologie und Klinik für Neurologie, Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Deutschland.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Berlin, Berlin, Deutschland
| | - S Köhler
- Klinik für Psychiatrie und Psychotherapie, Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - A Hasan
- Klinik für Psychiatrie und Psychotherapie, Ludwig Maximilians-Universität München, München, Deutschland
| | - P Falkai
- Klinik für Psychiatrie und Psychotherapie, Ludwig Maximilians-Universität München, München, Deutschland
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Tebartz van Elst L, Bechter K, Prüss H, Hasan A, Steiner J, Leypoldt F, Endres D. Autoantikörper-assoziierte schizophreniforme Psychosen: Pathophysiologie, Diagnostik und Therapie. DER NERVENARZT 2019; 90:745-761. [DOI: 10.1007/s00115-019-0735-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Petruzzelli MG, Margari L, Ivagnes S, Palumbi R, Margari F. Early onset first-episode psychosis during treatment with thalidomide for refractory ulcerative colitis: a case report. J Med Case Rep 2019; 13:175. [PMID: 31174605 PMCID: PMC6555996 DOI: 10.1186/s13256-019-2106-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/29/2019] [Indexed: 12/28/2022] Open
Abstract
Background Inflammatory bowel disease and schizophrenia spectrum disorders are complex and multifactorial conditions characterized by great variability of age at onset, clinical presentation, and longitudinal course. Several lines of evidence suggested different connections among immunological dysregulation, gastrointestinal inflammation, and psychosis, but to date many controversial issues still exist in this field. Case presentation We present the case of a 14-year-old Caucasian boy with refractory ulcerative colitis, admitted to the Child Neuropsychiatry Unit of the Polyclinic Hospital of Bari in the course of his first-episode psychosis. He showed an acute onset of psychotic symptomatology during treatment with thalidomide, an immunomodulatory drug used in the experimental therapy of refractory inflammatory bowel disease. Thalidomide was discontinued and orally administered mesalazine was restarted. In addition, treatment with antipsychotics and mood stabilizers was introduced with gradual improvement of psychotic symptoms. According to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, a diagnosis of partial remission of a first episode of schizoaffective disorder was formulated after a 6-month follow-up. Throughout this period, both psychopharmacological and mesalazine-based gastrointestinal treatments were maintained with partial remission of psychiatric and gastrointestinal symptoms. Conclusions We propose that refractory ulcerative colitis and psychosis might represent different manifestations of a common pathological pathway. However, it is also conceivable that thalidomide may have played a role in promoting the manifestation of psychotic symptoms in an individual with a specific vulnerability to schizoaffective disorders. Further investigations are needed to improve our knowledge regarding the complexity of brain–gut interactions, thus improving the management of co-existing inflammatory bowel and schizophrenia spectrum disorders.
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Affiliation(s)
- Maria Giuseppina Petruzzelli
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico Piazza, G. Cesare 11, 70124, Bari, Italy.
| | - Lucia Margari
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico Piazza, G. Cesare 11, 70124, Bari, Italy
| | - Sara Ivagnes
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico Piazza, G. Cesare 11, 70124, Bari, Italy
| | - Roberto Palumbi
- Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico Piazza, G. Cesare 11, 70124, Bari, Italy
| | - Francesco Margari
- Psychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Policlinico Piazza, G. Cesare 11, 70124, Bari, Italy
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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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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49
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Bechter K, Brown D, Najjar S. Editorial: Recent Advances in Psychiatry From Psycho-Neuro-Immunology Research: Autoimmune Encephalitis, Autoimmune Encephalopathy, and Mild Encephalitis. Front Psychiatry 2019; 10:169. [PMID: 31001151 PMCID: PMC6455066 DOI: 10.3389/fpsyt.2019.00169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/07/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Karl Bechter
- Department of Psychiatry and Psychotherapy II, Bezirkskrankenhaus Guenzburg, University of Ulm, Ulm, Germany
| | - David Brown
- Department of Immunopathology, ICPMR, Westmead Hospital, Westmead, NSW, Australia
| | - Souhel Najjar
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, United States
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50
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Herbsleb M, Keller-Varady K, Wobrock T, Hasan A, Schmitt A, Falkai P, Gabriel HHW, Bär KJ, Malchow B. The Influence of Continuous Exercising on Chronotropic Incompetence in Multi-Episode Schizophrenia. Front Psychiatry 2019; 10:90. [PMID: 30918486 PMCID: PMC6424878 DOI: 10.3389/fpsyt.2019.00090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/07/2019] [Indexed: 12/22/2022] Open
Abstract
People with schizophrenia die on average 15-20 years earlier than age and gender matched controls in the general population. An essential part of this excess mortality in people with schizophrenia is caused by physical illnesses. Among the physical illnesses, cardiovascular disease (CVD) has been identified as the most common natural cause of death in up to 40-45% of the cases. Chronotropic incompetence (CI) is defined as the inability of the heart to increase its beating frequency in proportion to increased physical activity or higher metabolic demand. It is an established independent cardiovascular risk factor for major cardiac events and overall mortality and might explain adaptation intolerance of the cardiovascular system to even minor exercise courses. CI needs objective exercise testing for definitive diagnosis and therefore represents a biological marker indicating the integrity of the cardiovascular system. It was recently described in patients with schizophrenia and might help explain the reduced physical fitness in these patients and the inability of a subgroup of patients to benefit from exercise interventions. In this study, we tried to replicate the occurrence of CI in an independent sample of patients with schizophrenia and evaluated whether CI can be influenced by a continuous endurance training of 12 weeks. Therefore, we re-analyzed the fitness testing data of 43 patients with schizophrenia and 22 aged and gender matched healthy controls. Parameters of aerobic fitness and chronotropic response to exercise were calculated. Patients with schizophrenia were less physically fit than the healthy controls and displayed a significantly higher heart rate at rest. 10 of 43 patients with schizophrenia and no healthy control subject were classified as chronotropically incompetent. Chronotropic response to exercise did not change significantly after 12 weeks of continuous aerobic exercise training. No differences were observed for baseline heart rate and peak heart rate in both subgroups of schizophrenia patients. Aerobic fitness did not improve significantly in the patients with schizophrenia classified as chronotropically incompetent. Our results confirm the occurrence of CI in patients with multi-episode schizophrenia. This should be taken into account when planning an exercise or lifestyle intervention studies in this population. Schizophrenia patients with CI do not seem to benefit as well as schizophrenia patients without CI from aerobic exercise training interventions. Larger, prospective randomized controlled clinical trials with different training interventions are urgently needed to address the topic of schizophrenia patients not responding to exercise and the relationship to the illness itself.
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Affiliation(s)
- Marco Herbsleb
- Psychiatric Brain and Body Research Group, Department of Psychiatry and Psychotherapy, University Hospital Jena, Jena, Germany.,Department of Sports Medicine and Health Promotion, Friedrich-Schiller-University of Jena, Jena, Germany
| | | | - Thomas Wobrock
- Department of Psychiatry and Psychotherapy, County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | - Andrea Schmitt
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany.,Laboratory of Neuroscience (LIM27), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | | | - Karl-Jürgen Bär
- Psychiatric Brain and Body Research Group, Department of Psychiatry and Psychotherapy, University Hospital Jena, Jena, Germany
| | - Berend Malchow
- Psychiatric Brain and Body Research Group, Department of Psychiatry and Psychotherapy, University Hospital Jena, Jena, Germany
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