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Cerne D, Losa M, Mattioli P, Lechiara A, Rebella G, Roccatagliata L, Arnaldi D, Schenone A, Morbelli S, Benedetti L, Massa F. Incident anti-LGI1 autoimmune encephalitis during dementia with Lewy bodies: when Occam razor is a double-edged sword. J Neuroimmunol 2024; 387:578291. [PMID: 38237526 DOI: 10.1016/j.jneuroim.2024.578291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 02/12/2024]
Abstract
In Dementia with Lewy bodies (DLB), rapid cognitive decline and seizures seldom complicate the typical clinical course. Nevertheless, concurrent, treatable conditions may be responsible. We report a case of DLB with superimposed anti-LGI1 encephalitis, emphasizing the importance of thorough diagnostic reasoning beyond the simplest explanation amid distinct clinical cues.
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Affiliation(s)
- Denise Cerne
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Mattia Losa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Mattioli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Anastasia Lechiara
- Autoimmunity Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giacomo Rebella
- Department of Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Luca Roccatagliata
- Department of Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Dario Arnaldi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Angelo Schenone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Federico Massa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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2
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Qin X, Li J, Luo Y, He Y, Xiao X, Tan A, Xiao J. Anti-contactin-associated protein-like 2 antibody autoimmune encephalitis with rapidly progressive parkinsonism: a case report and literature review. Acta Neurol Belg 2023; 123:2139-2146. [PMID: 36273369 DOI: 10.1007/s13760-022-02124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/14/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Anti-contactin-associated protein-like 2 (CASPR2) antibody encephalitis is a rare autoimmune encephalitis (AE) that often presents with epilepsy, cognitive dysfunction, peripheral neuropathy, autonomic nerve damage, and ataxia. Parkinsonism is often observed in neurodegenerative diseases but progresses slowly, and rapidly progressive parkinsonism is rare. Given that it is a curable parkinsonism, identifying and providing early immunotherapy is crucial. METHODS We reported a patient initially presenting with anxiety and depression, whose symptoms were relieved following mood regulation treatment. After discontinuation of the mood-regulating drugs, mood disorders recurred, accompanied by parkinsonism. The onset of parkinsonism was subacute (< 3-month disease course), and progression was rapid. After immunotherapy, all symptoms disappeared completely. We reviewed all relevant literature on anti-CASPR2 antibody encephalitis with parkinsonism. RESULTS Our literature review revealed three cases (including our patient): two male and one female, ranging in age from 48 to 72 years. All patients had parkinsonism, generalized tonic-clonic seizures, and hyponatremia. Three patients had anti-CASPR2 antibody positivity in the serum, and one patient had anti-CASPR2 antibody positivity in the CSF. All three patients were treated with anti-epileptic drugs and intravenous steroid pulse therapy, followed by oral steroid therapy, symptoms improved. CONCLUSION Parkinsonism can be easily misdiagnosed as a neurodegenerative disease, especially during the early stages. In patients with parkinsonism, treatable diseases should be considered in addition to neurodegenerative diseases. In clinical practice, anti-CASPR2 antibody encephalitis should be considered if rapidly progressing parkinsonism is encountered after ruling out common etiologies.
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Affiliation(s)
- Xiaohong Qin
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China.
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China.
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, No.33, 2Nd Road, Furong AvenueWenjiang District, Chengdu, 611731, Sichuan Province, China.
| | - Jieying Li
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China
| | - Yuanyuan Luo
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China
| | - Yunsen He
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Xiaoqiang Xiao
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China
| | - Arui Tan
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China
| | - Jun Xiao
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, 610072, China.
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, 610072, China.
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, No.33, 2Nd Road, Furong AvenueWenjiang District, Chengdu, 611731, Sichuan Province, China.
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3
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Adiguzel Y, Mahroum N, Muller S, Blank M, Halpert G, Shoenfeld Y. Shared Pathogenicity Features and Sequences between EBV, SARS-CoV-2, and HLA Class I Molecule-binding Motifs with a Potential Role in Autoimmunity. Clin Rev Allergy Immunol 2023; 65:206-230. [PMID: 37505416 DOI: 10.1007/s12016-023-08962-4] [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] [Accepted: 05/25/2023] [Indexed: 07/29/2023]
Abstract
Epstein-Barr virus (EBV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are extraordinary in their ability to activate autoimmunity as well as to induce diverse autoimmune diseases. Here we reviewed the current knowledge on their relation. Further, we suggested that molecular mimicry could be a possible common mechanism of autoimmunity induction in the susceptible individuals infected with SARS-CoV-2. Molecular mimicry between SARS-CoV-2 and human proteins, and EBV and human proteins, are present. Besides, relation of the pathogenicity associated with both coronavirus diseases and EBV supports the notion. As a proof-of-the-concept, we investigated 8mer sequences with shared 5mers of SARS-CoV-2, EBV, and human proteins, which were predicted as epitopes binding to the same human leukocyte antigen (HLA) supertype representatives. We identified significant number of human peptide sequences with predicted-affinities to the HLA-A*02:01 allele. Rest of the peptide sequences had predicted-affinities to the HLA-A*02:01, HLA-B*40:01, HLA-B*27:05, HLA-A*01:01, and HLA-B*39:01 alleles. Carriers of these serotypes can be under a higher risk of autoimmune response induction upon getting infected, through molecular mimicry-based mechanisms common to SARS-CoV-2 and EBV infections. We additionally reviewed established associations of the identified proteins with the EBV-related pathogenicity and with the autoimmune diseases.
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Affiliation(s)
- Yekbun Adiguzel
- Department of Medical Biology, School of Medicine, Atilim University, Kizilcasar Mah. 06836 Incek, Golbasi, Ankara, Turkey.
| | - Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Göztepe Mah, Atatürk Cd. No:40, Beykoz, Istanbul, 34810, Turkey
| | - Sylviane Muller
- Centre National de la Recherche scientifique-Université de Strasbourg, Biotechnology and Cell Signalling Unit, Neuroimmunology and Peptide Therapeutics Team, Strasbourg Drug Discovery and Development Institute, Strasbourg, France
- University of Strasbourg Institute for Advanced Study, Strasbourg, France
- Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Miri Blank
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Tel-Hashomer, 52621, Israel
| | - Gilad Halpert
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Tel-Hashomer, 52621, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Tel-Hashomer, 52621, Israel
- Reichman University, Herzliya, 4610101, Israel
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4
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Gövert F, Abrante L, Becktepe J, Balint B, Ganos C, Hofstadt-van Oy U, Krogias C, Varley J, Irani SR, Paneva S, Titulaer MJ, de Vries JM, Boon AJW, Schreurs MWJ, Joubert B, Honnorat J, Vogrig A, Ariño H, Sabater L, Dalmau J, Scotton S, Jacob S, Melzer N, Bien CG, Geis C, Lewerenz J, Prüss H, Wandinger KP, Deuschl G, Leypoldt F. Distinct movement disorders in contactin-associated-protein-like-2 antibody-associated autoimmune encephalitis. Brain 2023; 146:657-667. [PMID: 35875984 DOI: 10.1093/brain/awac276] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 06/02/2022] [Accepted: 06/22/2022] [Indexed: 11/14/2022] Open
Abstract
Autoimmune encephalitis can be classified into antibody-defined subtypes, which can manifest with immunotherapy-responsive movement disorders sometimes mimicking non-inflammatory aetiologies. In the elderly, anti-LGI1 and contactin associated protein like 2 (CASPR2) antibody-associated diseases compose a relevant fraction of autoimmune encephalitis. Patients with LGI1 autoantibodies are known to present with limbic encephalitis and additionally faciobrachial dystonic seizures may occur. However, the clinical spectrum of CASPR2 autoantibody-associated disorders is more diverse including limbic encephalitis, Morvan's syndrome, peripheral nerve hyperexcitability syndrome, ataxia, pain and sleep disorders. Reports on unusual, sometimes isolated and immunotherapy-responsive movement disorders in CASPR2 autoantibody-associated syndromes have caused substantial concern regarding necessity of autoantibody testing in patients with movement disorders. Therefore, we aimed to systematically assess their prevalence and manifestation in patients with CASPR2 autoimmunity. This international, retrospective cohort study included patients with CASPR2 autoimmunity from participating expert centres in Europe. Patients with ataxia and/or movement disorders were analysed in detail using questionnaires and video recordings. We recruited a comparator group with anti-LGI1 encephalitis from the GENERATE network. Characteristics were compared according to serostatus. We identified 164 patients with CASPR2 autoantibodies. Of these, 149 (90.8%) had only CASPR2 and 15 (9.1%) both CASPR2 and LGI1 autoantibodies. Compared to 105 patients with LGI1 encephalitis, patients with CASPR2 autoantibodies more often had movement disorders and/or ataxia (35.6 versus 3.8%; P < 0.001). This was evident in all subgroups: ataxia 22.6 versus 0.0%, myoclonus 14.6 versus 0.0%, tremor 11.0 versus 1.9%, or combinations thereof 9.8 versus 0.0% (all P < 0.001). The small group of patients double-positive for LGI1/CASPR2 autoantibodies (15/164) significantly more frequently had myoclonus, tremor, 'mixed movement disorders', Morvan's syndrome and underlying tumours. We observed distinct movement disorders in CASPR2 autoimmunity (14.6%): episodic ataxia (6.7%), paroxysmal orthostatic segmental myoclonus of the legs (3.7%) and continuous segmental spinal myoclonus (4.3%). These occurred together with further associated symptoms or signs suggestive of CASPR2 autoimmunity. However, 2/164 patients (1.2%) had isolated segmental spinal myoclonus. Movement disorders and ataxia are highly prevalent in CASPR2 autoimmunity. Paroxysmal orthostatic segmental myoclonus of the legs is a novel albeit rare manifestation. Further distinct movement disorders include isolated and combined segmental spinal myoclonus and autoimmune episodic ataxia.
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Affiliation(s)
- Felix Gövert
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Ligia Abrante
- Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Jos Becktepe
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Department of Neurology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, 10117 Berlin, Germany
| | | | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, 44791 Bochum, Germany
| | - James Varley
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sofija Paneva
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Juna M de Vries
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Agnita J W Boon
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marco W J Schreurs
- Department of Neurology, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Bastien Joubert
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Jerome Honnorat
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Alberto Vogrig
- Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon-Université Claude Bernard Lyon 1, Lyon, France
| | - Helena Ariño
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Lidia Sabater
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Josep Dalmau
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Neurology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA.,Catalan Institution for Research and Advanced Studies (ICREA), 08010 Barcelona, Spain
| | - Sangeeta Scotton
- Department of Neurology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University of Münster, 48149 Münster, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Bielefeld University, Medical School, Campus Bielefeld-Bethel, 33617 Bielefeld, Germany
| | - Christian Geis
- Department of Neurology, University of Jena, 07747 Jena, Germany
| | - Jan Lewerenz
- Department of Neurology, Ulm University, 89081 Ulm, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin and Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology, Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany.,Department of Neurology, University of Luebeck and University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany.,Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, 24105 Kiel, Germany
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5
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Devine MF, Feemster JC, Lieske EA, McCarter SJ, Sandness DJ, Steele T, Timm PC, Mandrekar J, Boeve BF, Silber MH, Dubey D, McKeon A, St. Louis EK. Objective sleep profile in LGI1/CASPR2 autoimmunity. Sleep 2022; 45:zsab297. [PMID: 34953167 PMCID: PMC8842336 DOI: 10.1093/sleep/zsab297] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
STUDY OBJECTIVES Rapid eye movement (REM) sleep behavior disorder (RBD) and other sleep disturbances are frequent in leucine-rich, glioma inactivated protein 1-IgG (LGI1) and contactin-associated protein 2-IgG (CASPR2) autoimmunity, yet polysomnographic analyses of these disorders remain limited. We aimed to characterize clinical presentations and analyze polysomnographic manifestations, especially quantitative REM sleep without atonia (RSWA) in LGI1/CASPR2-IgG seropositive (LGI/CASPR2+) patients. METHODS We retrospectively analyzed clinical and polysomnographic features and quantitative RSWA between LGI1+/CASPR2+ patients and age-sex matched controls. Groups were compared with Wilcoxon rank-sum and chi-square tests. Combined submentalis and anterior tibialis (SM + AT) RSWA was the primary outcome. RESULTS Among 11 (LGI1+, n = 9; CASPR2+, n = 2) patients, Morvan syndrome sleep features were present in seven (63.6%) LGI1+/CASPR2+ patients, with simultaneous insomnia and dream enactment behavior (DEB) in three (27.3%), and the most common presenting sleep disturbances were DEB (n = 5), insomnia (n = 5), and sleep apnea (n = 8; median apnea-hypopnea index = 15/hour). Median Epworth Sleepiness Scale was nine (range 3-24; n = 10), with hypersomnia in four (36.4%). LGI1+/CASPR2+ patients had increased N1 sleep (p = .02), decreased REM sleep (p = .001), and higher levels of SM + AT any RSWA (p < .001). Eight of nine (89%) LGI1+ exceeded RBD RSWA thresholds (DEB, n = 5; isolated RSWA, n = 3). RSWA was greater in AT than SM. All 10 LGI1+/CASPR2+ patients treated with immunotherapy benefitted, and 5/10 had improved sleep disturbances. CONCLUSIONS LGI1/CASPR2-IgG autoimmunity is associated with prominent dream enactment, insomnia, RSWA, sleep apnea, and shallower sleep. Polysomnography provides objective disease markers in LGI1+/CASPR2+ autoimmunity and immunotherapy may benefit associated sleep disturbances.
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Affiliation(s)
- Michelle F Devine
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Olmsted Medical Center, Rochester, MN, USA
| | - John C Feemster
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Elizabeth A Lieske
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Stuart J McCarter
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - David J Sandness
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Tyler Steele
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Paul C Timm
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Jay Mandrekar
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Biostatistics, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Bradley F Boeve
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Michael H Silber
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Pathology/Laboratory Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Pathology/Laboratory Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
| | - Erik K St. Louis
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Mayo Clinic and Foundation, Rochester, MN, USA
- Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA
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6
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Gadoth A, Segal Y, Paran Y, Aizenstein O, Alcalay Y. The importance of tissue-based assay in the diagnosis of autoimmune encephalitis. J Neurol 2022; 269:3588-3596. [DOI: 10.1007/s00415-022-10973-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/26/2021] [Accepted: 01/13/2022] [Indexed: 01/17/2023]
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7
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Miao A, Shi Y, Wang X, Ge J, Yu C. Clinical Features and Prognosis in Chinese Patients With Dipeptidyl–Peptidase–Like Protein 6 Antibody–Associated Encephalitis. Front Neurol 2022; 12:817896. [PMID: 35095748 PMCID: PMC8795695 DOI: 10.3389/fneur.2021.817896] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Anti-dipeptidyl–peptidase–like protein 6 (anti-DPPX) encephalitis an extremely rare type of immune-mediated encephalitis. This study aimed to analyze the electroclinical characteristics and prognosis of anti-DPPX encephalitis. Methods: Five patients (all male) with anti-DPPX encephalitis in East China from January 2016 to October 2021 was retrospective analyzed. Electroclinical features and outcomes were reviewed. Results: All five patients were male. The media age at disease onset was 32 years old with a range of 14–56 years. The main symptoms included psychiatric disturbances (2/5), amnesia (4/5), confusion (3/5), and seizures (3/5). Migrating myoclonus were identified in patient 4 with positive DPPX and contactin-associated protein-like 2 antibodies in blood. All of the patients had positive DPPX antibodies in serum. Only one of them had positive antibody in the cerebrospinal fluid. EEG showed diffuse slowing in two patients, but no epileptiform discharges were observed. Eighty percent (4/5) of the patients showed normal brain magnetic resonance imaging. After immunotherapy, improvement of neuropsychiatric symptoms from all of the patients was observed. Over a mean follow-up of 30.8 weeks, all of the patients had marked improvement in the modified Rankin Scale. To date, no tumors were not observed in any patients. Conclusions: Anti-DPPX encephalitis mainly presents as neuropsychiatric symptoms. Cooperation of DPPX antibodies and CASPR2 antibodies might have contributed to the migration of myoclonus in the patient 4. Prompt immunotherapy often results in improvement.
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Affiliation(s)
- Ailiang Miao
- Department of Neurology, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Department of Video-Electroencephalogram, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Ailiang Miao
| | - Yongwei Shi
- Department of Neurology, Taizhou Fourth People's Hospital, Taizhou, China
| | - Xiaoshan Wang
- Department of Neurology, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Jianqing Ge
- Department of Neurology, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chuanyong Yu
- Department of Neurology, Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
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8
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Tipton PW, Day GS, Graff-Radford N. A Neurologist's Practical Approach to Cognitive Impairment. Semin Neurol 2021; 41:686-698. [PMID: 34826872 DOI: 10.1055/s-0041-1726354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The global prevalence of dementia is expected to triple by the year 2050. This impending health care crisis has led to new heights of public awareness and general concern regarding cognitive impairment. Subsequently, clinicians are seeing more and more people presenting with cognitive concerns. It is important that clinicians meet these concerns with a strategy promoting accurate diagnoses. We have diagramed and described a practical approach to cognitive impairment. Through an algorithmic approach, we determine the presence and severity of cognitive impairment, systematically evaluate domains of function, and use this information to determine the next steps in evaluation. We also discuss how to proceed when cognitive impairment is associated with motor abnormalities or rapid progression.
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Affiliation(s)
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
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9
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Khatib L, Renard D, Honnorat J, Castelnovo G. Abdominal Segmental Myoclonus Mimicking Belly Dancer Dyskinesias in
CASPR2
Antibody Encephalomyelitis. Mov Disord Clin Pract 2021; 8:1260-1262. [PMID: 36988995 PMCID: PMC8564816 DOI: 10.1002/mdc3.13351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/01/2021] [Accepted: 09/05/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Laura Khatib
- Department of Neurology CHU de Nîmes, Univ. Montpellier Montpellier France
| | - Dimitri Renard
- Department of Neurology CHU de Nîmes, Univ. Montpellier Montpellier France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome Hospices Civils de Lyon, Hôpital Neurologique Bron France
- Institute NeuroMyoGène, INSERM U1217/CNRS UMR 5310 Université de Lyon, Université Claude Bernard Lyon 1 Lyon France
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10
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Chan F, O'Gorman C, Swayne A, Gillis D, Blum S, Warren N. Voltage-gated potassium channel blanket testing in first-episode psychosis: Diagnostic nihilism? Aust N Z J Psychiatry 2021; 55:817-823. [PMID: 33423505 DOI: 10.1177/0004867420983454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Voltage-gated potassium channel antibodies are implicated in limbic encephalitis and currently included in first-episode psychosis organic screening guidelines. Individuals with high-positive voltage-gated potassium channel titres most commonly present with neurological symptoms as well as sleep, cognitive, behaviour, psychosis and mood disturbance. The significance of low-positive voltage-gated potassium channel antibody titres in psychiatric patients is unclear and has not been previously examined. We aim to describe a statewide cohort of psychiatric patients with low- and high-positive voltage-gated potassium channel titres and explore if this finding influenced clinical management and patient outcomes. METHODS A retrospective review of all voltage-gated potassium channel antibodies testing performed in public psychiatric services in Queensland, Australia, with comparison of the clinical presentation and long-term outcomes of low- and high-positive voltage-gated potassium channel titre cases. Specific antigen targets (leucine-rich glioma-inactivated protein 1 and contactin-associated protein 2 antibodies) were also assessed. RESULTS The overall prevalence of voltage-gated potassium channel antibody positivity in Queensland, public, psychiatric service testing was 0.3% (14/4098), with 12 cases of low-positive voltage-gated potassium channel titre, 2 cases of high-positive (leucine-rich glioma-inactivated protein 1 antibody positive) cases and a voltage-gated potassium channel negative contactin-associated protein 2 antibody positive case. No low-positive case developed neurological abnormalities or had abnormal paraclinical investigations. In comparison, both high-positive voltage-gated potassium channel/leucine-rich glioma-inactivated protein 1 cases and the contactin-associated protein 2 antibody positive case rapidly developed neurological symptoms, had abnormal paraclinical testing and improved only with immunotherapy. There was no later development of encephalitic symptoms in the low-positive cases over an average of 1067 days follow-up. CONCLUSION Voltage-gated potassium channel antibody-associated limbic encephalitis was rare, and always associated with high antibody titres. Low-positive titres were not associated with the development of encephalitis over a long period of follow-up. The value of universal voltage-gated potassium channel antibody screening is unclear, and further prospective studies in first-episode psychosis populations are required.
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Affiliation(s)
- Fiona Chan
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew Swayne
- Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Gillis
- Queensland Pathology, Brisbane, QLD, Australia.,Immunology Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Stefan Blum
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health, Princess Alexandra Hospital, Brisbane, QLD, Australia
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11
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Antibody Testing for Suspected Autoimmune Autonomic Dysfunction and Small Fiber Neuropathies. J Clin Neurophysiol 2021; 38:274-278. [PMID: 34009850 DOI: 10.1097/wnp.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Autonomic dysfunction and small fiber neuropathies are heterogeneous disorders with a wide array of potential etiologies. As with other neurologic diseases, autoantibodies specific to neural tissue, either in the setting of cancer or systemic autoimmunity, may cause autonomic abnormalities. Given the complex and varied functions of the autonomic nervous system, however, the presentation of these conditions may be quite variable. This, in addition to pitfalls of autonomic testing especially for the novice, can lead to inaccuracies in recognizing and characterizing these conditions. We now have a large number of autoantibodies available for testing with more in the pipeline thanks to unprecedented developments in the field of neuroimmunology. Those have been very helpful in uncovering potentially treatable mechanisms of autonomic disease, but also pose a challenge to the clinician given their multiplicity and variable specificity. Growing knowledge regarding autoimmune autonomic implications and the autonomic specificities of each antibody, in addition to the increasing attention to the relevance of antibody titers are of utmost importance for clinicians concerned with autonomic neurology. This review attempts to shed a light on the frequently encountered antibodies in relation to autonomic dysfunction.
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12
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Saint M, Alakbarzade V, McLean B. Frontotemporal Dementia with Parkinsonism and Epilepsy Associated with VGKC Antibodies: Case Report and Literature Review. Case Rep Neurol 2021; 13:205-210. [PMID: 33976657 PMCID: PMC8077438 DOI: 10.1159/000513852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/08/2020] [Indexed: 11/19/2022] Open
Abstract
Antibodies directed against the voltage-gated potassium channel complex (anti-VGKCs) are implicated in several autoimmune conditions including limbic encephalitis and epilepsy. However, emerging evidence suggests that only specific subtypes of anti-VGKCs are pathogenic. We present the case of a 55-year-old man who initially presented with focal unaware seizures and behavioural changes mimicking anti-VGKC-seropositive encephalitis that further progressed to parkinsonism with evidence of frontotemporal dementia and pre-synaptic dopaminergic deficit. Aggressive treatment with immunotherapy was ineffective, and antibody subtyping later revealed the anti-VGKC antibodies to be negative for leucine-rich glioma-associated 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) − the two known pathogenic subtypes. The clinical relevance of so-called “double-negative” anti-VGKCs (i.e., those not directed towards LGI1 or CASPR2) has been called into question in recent years, with evidence to suggest they may be clinically insignificant. Our case emphasises the importance of antibody subtyping in cases of anti-VGKC seropositivity; negative results, particularly when combined with a poor response to immunotherapy, should prompt a rapid reconsideration of the working diagnosis.
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Affiliation(s)
- Matthew Saint
- College of Medicine and Health, Exeter, United Kingdom
| | - Vafa Alakbarzade
- Department of Neurology, Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom
| | - Brendan McLean
- Department of Neurology, Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom
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13
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Amin M, Li Y, Daly TM, Marquardt RJ. Evaluating the frequency of positive paraneoplastic antibodies and associated malignancy risk. J Neurol Sci 2021; 423:117347. [PMID: 33640579 DOI: 10.1016/j.jns.2021.117347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the association between malignancy and frequently positive paraneoplastic antibodies. METHODS A retrospective cohort study was carried out for all patients who received paraneoplastic antibody testing in 2013-2014 at a tertiary referral center. Available medical records on included patients were reviewed through July 2020. Patients were divided into antibody positive and negative subgroups. Focused analysis was performed on the subgroup of patients who received testing via a commonly used antibody panel. RESULTS A total of 1860 patients (the full cohort) received 19,323 antibody testing via panel or individual antibody testing, and were followed-up for a mean period of 36.2 months (range 0-83 months). Altogether 229 antibodies in 196 patients were positive, and 9 (3.9%) in 7 patients were against onconeuronal antigens. The remaining 220 (96.1%) were positive for mostly antibodies against cell surface or synaptic antigens. A total of 1161 patients received Mayo Clinic paraneoplastic antibody panel tests (the panel cohort), and 14.9% (173) of these patients possessed one or more positive antibodies. For the panel cohort, no difference was found between antibody positive and negative groups with respect to the prevalence of previously existing malignancy (15.6% versus 16.6%, p = 0.745) or incidence of new malignancy (4.0% vs. 3.7%, p = 0.848) during the follow-up period. No difference was observed in the incidence of new malignancy during follow-up between the antibody positive and negative groups for the 7 most frequently positive antibodies. CONCLUSIONS The presence of frequently positive antibodies, mostly to cell surface or synaptic antigens, is not clearly associated with the development of malignancy in the subsequent three years.
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Affiliation(s)
- Moein Amin
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Yuebing Li
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Thomas M Daly
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America; Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Robert J Marquardt
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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14
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Mehta TR, Nagarajan E. Polyradiculitis in autoimmune encephalitis: a case report and review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00192-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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15
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Yamakawa M, Mukaino A, Kimura A, Nagasako Y, Kitazaki Y, Maeda Y, Higuchi O, Takamatsu K, Watari M, Yoshikura N, Ikawa M, Sugimoto I, Sakurai Y, Matsuo H, Ando Y, Shimohata T, Nakane S. Antibodies to the α3 subunit of the ganglionic-type nicotinic acetylcholine receptors in patients with autoimmune encephalitis. J Neuroimmunol 2020; 349:577399. [PMID: 32980672 DOI: 10.1016/j.jneuroim.2020.577399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
Abstract
Since autonomic dysfunction is closely associated with autoimmune encephalitis (AE), the objective of this study was to determine the autonomic symptoms and the prevalence of anti-α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (gAChRα3) antibodies in the patients with AE. We reviewed the clinical features of 19 AE patients, and specifically analyzed sera for anti-gAChRα3 antibodies using the luciferase immunoprecipitation system (LIPS) assay. Cardiovascular autonomic symptoms were found to be common in patients with AE, and hypersalivation was seen only in patients with NMDAR encephalitis. LIPS detected anti-gAChRα3 antibodies in the sera from patients with AE (5/29, 26%). This study is the first to demonstrate that clinical characteristics including autonomic symptoms of AE patients with seropositivity for gAChR autoantibodies. It will be important to verify the role of gAChR antibodies in autonomic dysfunction and brain symptoms to clarify the pathogenesis of AE.
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Affiliation(s)
- Makoto Yamakawa
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akihiro Mukaino
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Nagasako
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuki Kitazaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yasushi Maeda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Osamu Higuchi
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Koutaro Takamatsu
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mari Watari
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nobuaki Yoshikura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Izumi Sugimoto
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | - Hidenori Matsuo
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
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16
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Michael S, Waters P, Irani SR. Stop testing for autoantibodies to the VGKC-complex: only request LGI1 and CASPR2. Pract Neurol 2020; 20:377-384. [DOI: 10.1136/practneurol-2019-002494] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 12/16/2022]
Abstract
Autoantibodies to leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein like-2 (CASPR2) are associated with clinically distinctive syndromes that are highly immunotherapy responsive, such as limbic encephalitis, faciobrachial dystonic seizures, Morvan’s syndrome and neuromyotonia. These autoantibodies target surface-exposed domains of LGI1 or CASPR2, and appear to be directly pathogenic. In contrast, voltage-gated potassium channel (VGKC) antibodies that lack LGI1 or CASPR2 reactivities (‘double-negative’) are common in healthy controls and have no consistent associations with distinct syndromes. These antibodies target intracellular epitopes and lack pathogenic potential. Moreover, the clinically important LGI1 and CASPR2 antibodies comprise only ~15% of VGKC-positive results, meaning that most VGKC-antibody positive results mislead rather than help. Further, initial VGKC testing misses some cases that have LGI1 and CASPR2 antibodies. These collective observations confirm that laboratories should stop testing for VGKC antibodies and instead, test only for LGI1 and CASPR2 antibodies. This change in practice will lead to significant patient benefit.
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17
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Abstract
PURPOSE OF REVIEW To review sleep complaints reported in patients with autoimmune encephalitis, explore the relationship between sleep disturbances and subtypes of autoimmune encephalitis, and leverage knowledge concerning antibody-antigen specificity to inform the receptors, structures, and disseminated neural networks that contribute to sleep function in health and disease. RECENT FINDINGS Autoimmune encephalitis is an inflammatory brain disorder characterized by the subacute onset of psychiatric symptoms, cognitive impairment, and focal neurologic deficits or seizures. Sleep disturbances are detected in a majority of patients systematically screened for sleep complaints, may be the presenting symptom in patients with autoimmune encephalitis, and may compromise recovery in patients with autoimmune encephalitis. Early recognition of specific sleep disturbances in patients with subacute changes in behavior or cognition may support the diagnosis of autoimmune encephalitis. Similarly, recognition and treatment of sleep dysfunction in patients with known autoimmune encephalitis may speed recovery and improve long-term outcomes.
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Affiliation(s)
- Margaret S Blattner
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, USA.
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18
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Johnson DC, Kline Feldman DE, Marri P. The Rare Case of Anti-VGKC Limbic Encephalitis Secondary to High-Grade Glioma. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0039-1678662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AbstractParaneoplastic limbic encephalitis secondary to a glial tumor is rare, and limited reports on this occurrence have been made in the pediatric population. This case involves a 13-year-old female patient with anti-voltage gated potassium channel (anti-VGKC) limbic encephalitis secondary to a high-grade glioma (HGG) in the suprasellar region. HHGs, associated with anti-VGKC antibodies, are a rare occurrence. This case highlights the need for the inclusion of glial neoplasms in the differential diagnosis for patients presenting with symptoms associated with paraneoplastic encephalitis.
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Affiliation(s)
- DeJarra Caprii Johnson
- University of South Alabama College of Medicine, Mobile, Alabama, United States
- Department of Pediatrics, Children's and Women's Hospital, Mobile, Alabama, United States
| | | | - Preethi Marri
- Department of Pediatrics, Children's and Women's Hospital, Mobile, Alabama, United States
- Division of Hematology-Oncology, Children's and Women's Hospital, Mobile, Alabama, United States
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19
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Gövert F, Leypoldt F, Junker R, Wandinger KP, Deuschl G, Bhatia KP, Balint B. Antibody-related movement disorders - a comprehensive review of phenotype-autoantibody correlations and a guide to testing. Neurol Res Pract 2020; 2:6. [PMID: 33324912 PMCID: PMC7650144 DOI: 10.1186/s42466-020-0053-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/03/2020] [Indexed: 12/25/2022] Open
Abstract
Background Over the past decade increasing scientific progress in the field of autoantibody-mediated neurological diseases was achieved. Movement disorders are a frequent and often prominent feature in such diseases which are potentially treatable. Main body Antibody-mediated movement disorders encompass a large clinical spectrum of diverse neurologic disorders occurring either in isolation or accompanying more complex autoimmune encephalopathic diseases. Since autoimmune movement disorders can easily be misdiagnosed as neurodegenerative or metabolic conditions, appropriate immunotherapy can be delayed or even missed. Recognition of typical clinical patterns is important to reach the correct diagnosis. Conclusion There is a growing number of newly discovered antibodies which can cause movement disorders. Several antibodies can cause distinctive phenotypes of movement disorders which are important to be aware of. Early diagnosis is important because immunotherapy can result in major improvement.In this review article we summarize the current knowledge of autoimmune movement disorders from a point of view focused on clinical syndromes. We discuss associated clinical phenomenology and antineuronal antibodies together with alternative etiologies with the aim of providing a diagnostic framework for clinicians considering underlying autoimmunity in patients with movement disorders.
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Affiliation(s)
- Felix Gövert
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany.,Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel/Luebeck, Germany
| | - Ralf Junker
- Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel/Luebeck, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology, Institute of Clinical Chemistry, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel/Luebeck, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrecht University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK.,Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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20
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Abstract
PURPOSE OF REVIEW This article offers clinicians a strategic approach for making sense of a symptom complex that contains myoclonus. The article presents an evaluation strategy that highly leverages the two major classification schemes of myoclonus. The goal of this article is to link evaluation strategy with diagnosis and treatment of myoclonus. RECENT FINDINGS The growth of medical literature has helped better define myoclonus etiologies. Physiologic study of myoclonus types and etiologies with electrophysiologic testing has provided greater clarity to the pathophysiology of the myoclonus in various diseases. Although studies have been limited, the role of newer treatment agents and methods has made progress. SUMMARY Myoclonus has hundreds of different etiologies. Classification is necessary to evaluate myoclonus efficiently and pragmatically. The classification of myoclonus etiology, which is grouped by different clinical presentations, helps determine the etiology and treatment of the myoclonus. The classification of myoclonus physiology using electrophysiologic test results helps determine the pathophysiology of the myoclonus and can be used to strategize symptomatic treatment approaches. Both basic ancillary testing (including EEG and imaging) and more comprehensive testing may be necessary. Treatment of the underlying etiology is the ideal approach. However, if such treatment is not possible or is delayed, symptomatic treatment guided by the myoclonus physiology should be considered. More controlled study of myoclonus treatment is needed. Further research on myoclonus generation mechanisms should shed light on future treatment possibilities.
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21
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Liu X, Han Y, Yang L, Wang B, Shao S, Feng Y, Pang Z, Du Y, Lin Y. The exploration of the spectrum of motor manifestations of anti-LGI1 encephalitis beyond FBDS. Seizure 2020; 76:22-27. [PMID: 31972532 DOI: 10.1016/j.seizure.2019.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/21/2019] [Accepted: 12/22/2019] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The purpose of this study was to characterize the spectrum of motor events in patients with acute anti-leucine-rich glioma-inactivated protein 1 (anti-LGI1) encephalitis through video-electroencephalogram (VEEG) recordings. METHOD We collected data retrospectively from 16 patients diagnosed with anti-LGI1 encephalitis who had completed VEEG recording during hospitalization. RESULTS VEEG monitoring lasted a median of 11.0 h (range 4.5∼20). Fourteen types of seizures were recorded in 9 patients (56.3 %). Eight of the 14 types of seizures demonstrated typical ictal EEG evolution (including 2 subclinical seizures), 3/14 demonstrated EEG electrodecremental events (EDE) at onset but without further evolution, and 3/14 could be only judged by analyzing semiology. FBDS was recorded in 6 patients (37.5 %), and all these attacks were followed by epileptic seizures. Simple hyperkinetic movements (HMs), such as jerk-like or twisting movements, were found in 8 (50 %) patients, and 6 of them had complex HMs, such as manipulating movements or mimics of daily activities, during sleep. CONCLUSIONS 1. Atypical seizures, for instance, seizures without EEG evolution, are not rare but likely to be overlooked. 2. FBDS is closely linked with epileptic seizures, revealing FBDS to be a part of epileptic attacks. 3. HMs could expand the spectrum of motor manifestations, overlapping with sleep disorders. 4. The high prevalence of these motor events might be due to the disrupted cortical-subcortical network, which is critical in motor control and sleep.
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Affiliation(s)
- Xiaoyun Liu
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Yuxiang Han
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Liling Yang
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Bao Wang
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China; Shandong Medical Imaging Research Institue, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Sai Shao
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China; Shandong Medical Imaging Research Institue, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Yabo Feng
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Zaiying Pang
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Yifeng Du
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China
| | - Youting Lin
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Neurology, No 324, Jingwu Road, Huaiyin Zone, Jinan City, Shandong Province, 250012, PR China.
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22
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Zidan A, Fein A, Zuchowski K. The use, misuse and abuse of paraneoplastic panels in neurological disorders. A retrospective study. Clin Neurol Neurosurg 2019; 186:105545. [PMID: 31622896 DOI: 10.1016/j.clineuro.2019.105545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The field of paraneoplastic neurological syndromes PNS has grown exponentially with the increased identification of associated antibodies. Testing for these antibodies is commonly done in "panels" to increase sensitivity, and these panels have become a routine test on CSF samples obtained for a variety of clinical indications. Excessive testing has raised concerns about the correct utilization of these panels. Our study investigates the appropriateness of use of paraneoplastic panel in an academic, tertiary-care medical center. PATIENTS AND METHODS We retrospectively reviewed charts of all patients who had autoimmune paraneoplastic panel testing in one year period. We collected date on demographics, clinical presentations and ancillary testings on all reviewed charts. Then, we devised an algorithm based on available data to define cases where testing had been unnecessary or likely unnecessary. RESULTS We collected 60 cases that had undergone autoimmune paraneoplastic testing serum and/or CSF. Testing was unnecessary in 10 cases (16%), in which presentations had a definitive confirmatory tests. Testing was unlikely necessary in 11 cases (18%), in which all ancillary testing was normal in 6 cases, and presentation was not compatible with any known syndrome in 5 cases. Collectively, paraneoplastic panel testing was of extremely low yield on more than one third of the cases where where w testing was done. CONCLUSION Our results adds to the growing concerns about the utilization of paraneoplastic panels, and the urgent need for enhanced screening and establishing a framework that can guide neurologists on when testing can have a sufficient yield to warrant it. Such framework should be built using diagnostic algorithms based on risk, clinical manifestations, characterization of autoantibodies and their associations.
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23
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Chowdhry M, Gajulapalli SP, Agrawal S. A case study: Therapeutic plasma exchange in voltage-gated potassium channel autoimmune encephalitis. Transfus Apher Sci 2019; 59:102590. [PMID: 31378682 DOI: 10.1016/j.transci.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 06/27/2019] [Accepted: 07/05/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Neurological syndromes associated with voltage-gated potassium channels (VGKC) affect the nerve and muscle physiology. Presence of antibodies to VGKC are associated with three main neurologic syndromes namely neuromyotonia (NMT), limbic encephalitis (LE) and Morvan's syndrome(MVS) LE is a variably treatable neurologic syndrome associated with high levels of antibodies to the voltage-gated potassium channel (VGKC) complex. These antibodies are directed against protein antigens that bind to the VGKC complex. These antigens are usually leucine-rich, glioma inactivated 1 (LGI1), and contactin associated protein-like 2 (CASPR2). CASE DESCRIPTION A 58-year-old female and with a known case of auto immune encephalitis (voltage gated potassium channel) and steroid induced diabetes mellitus presented with progressive worsening of vertigo, recurrent myoclonic jerks and post ictal confusion for last 7 days. She had memory impairment since last few months. She was on treatment with steroids which were gradually tapered off 11 months back. CSF was tested for presence of VGKC antibodies and the test was positive for LGI (leucine-rich glioma inactivated 1) antibody. Therapeutic plasma exchange (TPE) was scheduled every day for 6 consecutive days based upon the recommendations from the ASFA guidelines for the treatment of neurologic syndromes. CONCLUSION TPE done every day in patient diagnosed LE with VGKC antibodies had shown rapid improvement in controlling the symptoms.
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Affiliation(s)
- Mohit Chowdhry
- Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi, India.
| | | | - Soma Agrawal
- Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi, India
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Freund B, Probasco JC, Cervenka MC, Sutter R, Kaplan PW. EEG Differences in Two Clinically Similar Rapid Dementias: Voltage-Gated Potassium Channel Complex-Associated Autoimmune Encephalitis and Creutzfeldt-Jakob Disease. Clin EEG Neurosci 2019; 50:121-128. [PMID: 29788790 DOI: 10.1177/1550059418774686] [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: 11/15/2022]
Abstract
Distinguishing treatable causes for rapidly progressive dementia from those that are incurable is vital. Creutzfeldt-Jakob disease (CJD) and voltage-gated potassium channel complex-associated autoimmune encephalitis (VGKC AE) are 2 such conditions with disparate outcomes and response to treatment. To determine the differences in electroencephalography between CJD and VGKC AE, we performed a retrospective review of medical records and examined clinical data, neuroimaging, and electroencephalographs performed in patients admitted for evaluation for rapidly progressive dementia diagnosed with CJD and VGKC AE at the Johns Hopkins Hospital and Bayview Medical Center between January 1, 2007 and December 31, 2015. More patients in the VGKC AE group had seizures (12/17) than those with CJD (3/14; P = .008). Serum sodium levels were lower in those with VGKC AE (P = .001). Cerebrospinal fluid (CSF) white blood cell count was higher in VGKC AE (P = .008). CSF protein 14-3-3 (P = .018) was more commonly detected in CJD, and tau levels were higher in those with CJD (P < .006). On neuroimaging, diffusion restriction in the cortex (P = .001), caudate (P < .001), and putamen (P = .001) was more frequent in CJD. Periodic sharp wave complexes (P = .001) and generalized suppressed activity (P = .008) were more common on initial EEG in CJD. On serial EEGs, generalized periodic discharges (P = .004), generalized suppressed activity (P=0.008), and periodic sharp wave complexes (P < .001) were detected more in CJD. This study shows that there are a number of differentiating features between CJD and VGKC AE, and electroencephalography can aid in their diagnoses. Performing serial EEGs better delineates these conditions.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John C Probasco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Raoul Sutter
- Department of Neurology and Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Sato M, Kishida D, Miyazaki D, Sekijima Y. A Patient with Limbic Encephalitis Associated with Anti-leucine-rich Glioma-inactivated 1 (LGI1) Antibody Presenting with Slowly Progressive Cognitive Impairment and Fluctuating Striatal Lesions. Intern Med 2019; 58:287-291. [PMID: 30146575 PMCID: PMC6378158 DOI: 10.2169/internalmedicine.1082-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We herein report the case of a 59-year-old man with anti-leucine-rich glioma-inactivated 1 (LGI1) antibody encephalitis who presented with slowly progressive cognitive impairment mimicking dementia for over 3 years and then developed seizures. Unique brain magnetic resonance imaging (MRI) findings of fluctuating striatal lesions were observed during the disease course. He was treated with intravenous methylprednisolone pulse therapy followed by oral prednisolone, which dramatically improved his neurological function. Taken together, these findings indicate that anti-LGI1 encephalitis may present as slowly progressive cognitive impairment mimicking dementia and that fluctuating MRI striatal lesions may be a characteristic radiological finding of this disorder.
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Affiliation(s)
- Mitsuto Sato
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Daigo Miyazaki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
- Institute for Biomedical Sciences, Shinshu University, Japan
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Barba C, Alexopoulos H. Parkinsonism in autoimmune diseases. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:419-452. [DOI: 10.1016/bs.irn.2019.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Neuromyotonic and myokymic discharges are abnormal electrical muscular discharges caused by ectopic discharges from motor axons and represent the hallmarks of peripheral nerve hyperexcitability. Neuromyotonic discharges are specific for peripheral nerve hyperexcitability syndromes, whereas myokymic discharges may occur either focally or in a more generalized fashion in many other peripheral nerve disorders. Isaacs syndrome and Morvan syndrome are rare acquired peripheral nerve hyperexcitability disorders that share common clinical features and are often associated with elevated voltage-gated potassium channel-complex antibodies. Central nervous system symptomatology is more common in Morvan syndrome, which also overlaps with limbic encephalitis. Cramp-fasciculation syndrome, a more common syndrome, may represent a milder form of peripheral nerve hyperexcitability. Peripheral nerve hyperexcitability syndromes should be distinguished from stiff person syndrome, myotonic disorders, and rippling muscle disease. When severe, Isaacs syndrome and Morvan syndrome may be disabling but often respond to membrane-stabilizing drugs and immunomodulatory treatments. The electrophysiologic features of these disorders are described.
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Affiliation(s)
- Bashar Katirji
- Neuromuscular Center and EMG Laboratory, Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States.
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Abstract
OBJECTIVE: To describe a case of leucine-rich, glioma inactivated 1 antibody-encephalitis presenting with psychosis. METHODS: Case report. RESULTS: A young man with leucine-rich, glioma inactivated 1-antibody encephalitis initially presented with acute psychotic symptoms, short-term memory loss and faciobrachial dystonic seizures. Magnetic resonance imaging revealed hippocampal lesions. Electroencephalography revealed frontotemporal slowing of background activity. CONCLUSION: Increased awareness of leucine-rich, glioma inactivated 1-antibody encephalitis may promote early recognition and treatment.
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Affiliation(s)
- Dahai Wang
- Doctor, Department of Psychiatry, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, China
| | - Qinjian Hao
- Resident Doctor, Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, China
| | - Lan He
- Doctor, Emergency Department, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, China
| | - Qiang Wang
- Professor, Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, China
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Ebright MJ, Li SH, Reynolds E, Burke JF, Claytor BR, Grisold A, Banerjee M, Callaghan BC. Unintended consequences of Mayo paraneoplastic evaluations. Neurology 2018; 91:e2057-e2066. [PMID: 30366974 PMCID: PMC6282240 DOI: 10.1212/wnl.0000000000006577] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the proportion of true and false positives from paraneoplastic panels and effects on downstream testing/treatment. METHODS Using a retrospective cohort study design, we identified 500 consecutive patients with Mayo paraneoplastic autoantibody testing and performed chart abstraction. Paraneoplastic presentation types were categorized into probable, possible, and other by consensus. True positives were defined as a positive antibody titer with no other explanation found in addition to one of the following: syndrome known to be associated with the antibody, clinical improvement with treatment, and new malignancy. Comparisons of diagnostic testing and treatments between false and true positives were performed. Multivariable logistic regression was used to evaluate associations between patient-level factors and true positives. RESULTS The mean (SD) age of the population was 55.4 (17.1) years, and 55.4% were female, with 1.3 (1.2) years of follow-up. Of the 500 tests, 87 (17.4%, 95% confidence interval [CI] 14.1%-20.7%) were positive and 62 (71.3%, 95% CI 61.8%-80.8%) of these were false positives. Of those with a possible/other presentation (n = 369), 2 (0.5%, 95% CI 0.0%-1.0%) were true positives. CT of the chest (30.7% vs 11.8%, p ≤ 0.01) was performed more often in false positives than true negatives. Probable presentation type (odds ratio [OR] 57.9, 95% CI 12.5-268.0) and outpatient setting (OR 8.7, 95% CI 2.4-31.8) were associated with true-positive results. CONCLUSION Paraneoplastic tests result in a large proportion of false positives, particularly in those with clinical presentations that are not well established as paraneoplastic diseases. Future work should construct panels targeted to specific clinical presentations and ensure that tests are ordered in the appropriate clinical context.
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Affiliation(s)
- Matthew J Ebright
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Shih-Hon Li
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Evan Reynolds
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - James F Burke
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Ben R Claytor
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Anna Grisold
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Mousumi Banerjee
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria
| | - Brian C Callaghan
- From the Health Services Research Program (M.J.E., J.F.B., B.R.C., B.C.C.), Department of Neurology, Department of Pathology (S.-H.L.), and Department of Biostatistics (E.R., M.B.), School of Public Health, University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; and Department of Neurology (A.G.), Medical University of Vienna, Austria.
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Naides SJ. The role of the laboratory in the expanding field of neuroimmunology: Autoantibodies to neural targets. J Immunol Methods 2018; 463:1-20. [PMID: 30300607 DOI: 10.1016/j.jim.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022]
Abstract
Accelerated identification of autoantibodies associated with previously idiopathic neurological disease has provided insights into disease mechanisms, enhanced understanding of neurological function, and opportunities for improved therapeutic interventions. The role of the laboratory in the expanding field of neuroimmunology is critical as specific autoantibody identification provides guidance to clinicians in diagnosis, prognosis, tumor search strategies, and therapeutic interventions. The number of specific autoantibodies identified continues to increase and newer testing strategies increase efficiencies in the laboratory and availability to clinicians. The need for broadly targeted efficient testing is underscored by the variability in clinical presentation and tumor associations attributable to a specific autoantibody, and conversely the various autoantibody specificities that can be the cause of a given clinical presentation. While many of the antineural antibodies were first recognized in the setting of neoplastic disease, idiopathic autoimmune neurological disease in the absence of underlying tumor is increasingly recognized. Appropriation of therapeutic modalities used to treat autoimmune disease to treat these autoantibody mediated neurological diseases has improved patient outcomes. Interaction between clinicians and laboratorians is critical to our understanding of these diseases and optimization of the clinical benefits of our increasing knowledge in neuroimmunology.
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Affiliation(s)
- Stanley J Naides
- Immunology R&D, Quest Diagnostics Nichols Institute, 33608 Ortega Highway, San Juan Capistrano, CA 92675, USA.
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Guerin J, Watson RE, Carr CM, Liebo GB, Kotsenas AL. Autoimmune epilepsy: findings on MRI and FDG-PET. Br J Radiol 2018; 92:20170869. [PMID: 30235015 DOI: 10.1259/bjr.20170869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Autoimmune epilepsy (AE) is becoming increasingly recognized as a potentially reversible cause of frequent or medically intractable seizures and cognitive deterioration. We describe various presentations of autoimmune encephalopathy which have specifically presented with seizure and describe reported imaging findings. This is organized as a review of the more common autoantibodies which can specifically precipitate seizure according to the intracellular or extracellular location of the targeted antigen. For each antibody, we illustrate their pathophysiology, characteristic clinical presentations with typical effective treatments and prognoses and imaging findings on MRI and PET/CT exams. Parenchymal involvement is variable with the limbic structures typically affected; however, non-limbic cortex, cerebellum, brainstem and basal ganglia can also be involved. In the acute setting, affected regions typically demonstrate T2 hyperintensity with mild mass effect from edema and increased 18F-fludeoxyglucose uptake. Chronically involved parenchyma will often undergo atrophy and demonstrate decreased metabolism; mesial temporal sclerosis is often the end result when the limbic system is involved. Without treatment, long-term effects from AE range from ongoing cognitive dysfunction and refractory seizures to death. Familiarity with AE may prompt appropriate antibody screening, particularly in cases of refractory seizure disorders. Early investigation and proper management of AE cases may help to prevent parenchymal and neurologic deterioration in these patients.
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Affiliation(s)
- Julie Guerin
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Robert E Watson
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Carrie M Carr
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Greta B Liebo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Amy L Kotsenas
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
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Abstract
PURPOSE OF REVIEW This article provides a review of the clinical phenotypes and evaluation of peripheral nerve hyperexcitability syndromes. These rare diagnoses include cramp-fasciculation syndrome, Isaacs syndrome, and Morvan syndrome. Recent investigations have led to an understanding of the autoimmune underpinnings of these conditions and their specific associated antibodies. As the presentation of peripheral nerve hyperexcitability syndromes includes muscle stiffness, twitches, and spasms, which are also shared with certain central nervous system and myopathic conditions, the differential diagnosis of peripheral nerve hyperexcitability syndromes is reviewed. RECENT FINDINGS Peripheral nerve hyperexcitability syndromes share clinical and electrodiagnostic evidence of motor nerve instability; however, their clinical presentations are varied. Case reviews have helped us understand the spectrum of symptoms associated with the three peripheral nerve hyperexcitability syndromes reviewed here: cramp-fasciculation syndrome, Isaacs syndrome, and Morvan syndrome. More recently, research has focused on understanding the voltage-gated potassium channel complex antibodies as well as neoplasms associated with these conditions. SUMMARY The diagnosis of peripheral nerve hyperexcitability syndromes requires a high index of suspicion, support from the physical examination, familiarity with the spectrum of symptoms associated with peripheral nerve hyperexcitability syndromes, and recognition of diagnostic EMG features. Voltage-gated potassium channel complex antibodies are associated with these conditions. Optimum treatment and autoimmune pathogenesis remain areas of active research.
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Co-morbid sleep disorders and epilepsy: A narrative review and case examples. Epilepsy Res 2018; 145:185-197. [PMID: 30048932 DOI: 10.1016/j.eplepsyres.2018.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/08/2018] [Accepted: 07/14/2018] [Indexed: 01/03/2023]
Abstract
Co-morbid sleep disorders, including sleep apnea, insomnia, restless legs syndrome, and the parasomnias, occur frequently in people with epilepsy. This article reviews the cardinal presenting symptoms and diagnostic features of each of these disorders to enable epileptologists to readily screen and identify sleep co-morbidities in their patients. It summarizes current evidence concerning the reciprocal relationship between sleep disturbances and epilepsy and available treatment options for common sleep disorders in people with epilepsy. Several illustrative cases demonstrate the practical consequences of co-morbid sleep disorders in epilepsy patients and suggest diagnostic and treatment approaches that may improve daytime functioning, alertness, quality of life, and seizure burden.
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Serdaroğlu E, Tezer Fİ, Saygi S. Autoimmune Epilepsy and/or Limbic Encephalitis Can Lead to Changes in Sleep Spindles. ACTA ACUST UNITED AC 2018; 55:320-324. [PMID: 30622387 DOI: 10.5152/npa.2017.19442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/09/2017] [Indexed: 11/22/2022]
Abstract
Introduction Sleep disorders have been described in patients with autoimmune limbic encephalitis (LE). The changes in sleep structure were also reported. Recently sleep spindle abnormalities such as asynchronous or prolonged spindles were observed children with LE. Methods We studied the sleep and number of sleep spindles in the continuous electroencephalography-polysomnography (EEG-PSG) recordings of 6 patients with autoimmune epilepsy and/or LE. The longest NREM 2 period was selected. We evaluated the spindle density (spindles per minute), and compared that to the spindle densities of epilepsy patients with bilateral hippocampal sclerosis and healthy controls. Results We have demonstrated that patients with autoimmune epilepsy and/or LE had reduced slow wave sleep with decreased number of sleep spindles. The mean number of spindles in 60 seconds was 5.86±5.03 in patients with autoimmune epilepsy and/or LE. But spindle density was higher in two control groups (10.6±1.65 and 9.95±0.79). Conclusions The sleep abnormalities in LE can result from the disruption of thalamo-limbic circuits, and lead to changes in spindle wave activity. Although density of spindles decreased with acute lesions in thalamo-limbic circuits, the relations with structural lesions or chronicity of disease are not clear. That may be related to functional disruption of neural circuitry.
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Affiliation(s)
- Esra Serdaroğlu
- Pediatric Neurology Department, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - F İrsel Tezer
- Neurology Department, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Serap Saygi
- Neurology Department, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Symmonds M, Moran CH, Leite MI, Buckley C, Irani SR, Stephan KE, Friston KJ, Moran RJ. Ion channels in EEG: isolating channel dysfunction in NMDA receptor antibody encephalitis. Brain 2018; 141:1691-1702. [PMID: 29718139 PMCID: PMC6207885 DOI: 10.1093/brain/awy107] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 12/15/2022] Open
Abstract
See Roberts and Breakspear (doi:10.1093/brain/awy136) for a scientific commentary on this article.Neurological and psychiatric practice frequently lack diagnostic probes that can assess mechanisms of neuronal communication non-invasively in humans. In N-methyl-d-aspartate (NMDA) receptor antibody encephalitis, functional molecular assays are particularly important given the presence of NMDA antibodies in healthy populations, the multifarious symptomology and the lack of radiological signs. Recent advances in biophysical modelling techniques suggest that inferring cellular-level properties of neural circuits from macroscopic measures of brain activity is possible. Here, we estimated receptor function from EEG in patients with NMDA receptor antibody encephalitis (n = 29) as well as from encephalopathic and neurological patient controls (n = 36). We show that the autoimmune patients exhibit distinct fronto-parietal network changes from which ion channel estimates can be obtained using a microcircuit model. Specifically, a dynamic causal model of EEG data applied to spontaneous brain responses identifies a selective deficit in signalling at NMDA receptors in patients with NMDA receptor antibody encephalitis but not at other ionotropic receptors. Moreover, though these changes are observed across brain regions, these effects predominate at the NMDA receptors of excitatory neurons rather than at inhibitory interneurons. Given that EEG is a ubiquitously available clinical method, our findings suggest a unique re-purposing of EEG data as an assay of brain network dysfunction at the molecular level.
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Affiliation(s)
- Mkael Symmonds
- Division of Clinical Neurology, John Radcliffe Hospital, Oxford, UK
- Department of Clinical Neurophysiology, John Radcliffe Hospital, Oxford, UK
- Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, Oxford, UK
| | - Catherine H Moran
- Department of Neurological Surgery, Beaumont Hospital, Dublin, Ireland
| | - M Isabel Leite
- Division of Clinical Neurology, John Radcliffe Hospital, Oxford, UK
- Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, Oxford, UK
| | - Camilla Buckley
- Division of Clinical Neurology, John Radcliffe Hospital, Oxford, UK
| | - Sarosh R Irani
- Division of Clinical Neurology, John Radcliffe Hospital, Oxford, UK
- Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, Oxford, UK
| | - Klaas Enno Stephan
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, 6 Wilfriedstrasse, Zurich, Switzerland
| | - Karl J Friston
- Wellcome Trust Centre for Neuroimaging, University College London, 12 Queen Square, London, UK
| | - Rosalyn J Moran
- Department of Engineering Mathematics, Merchant Venturers School of Engineering, University of Bristol, 75 Woodland Rd, Bristol, UK
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Ashat M, Lewis A, Liaquat H, Stocker A, McElmurray L, Vedanarayanan V, Soota K, Howell T, Kedar A, Obert J, Abell TL. Intravenous immunoglobulin in drug and device refractory patients with the symptoms of gastroparesis-an open-label study. Neurogastroenterol Motil 2018; 30. [PMID: 29205691 DOI: 10.1111/nmo.13256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 10/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroparesis is a complex clinical entity; many aspects of which remain unknown. Although most patients have idiopathic, diabetic, or postsurgical gastroparesis, many are thought to have measurable neuromuscular abnormalities. Immunotherapy has recently been utilized to treat suspected autoimmune gastrointestinal dysmotility. METHODS Fourteen patients with symptoms of gastroparesis (Gp) who were refractory to drug/device were selected from 443 Gp patients from 2013 to 2015 who were treated at the University of Louisville motility center. All patients underwent a structural and psychiatric evaluation along with detailed psychological and behavioral examination to rule out eating disorders. We performed detailed neuromuscular evaluation and all 14 patients received at least 12 weeks of intravenous immunoglobulin (400 mg/kg infusion weekly). Response was defined subjectively (symptomatic improvement) using standardized IDIOM score system. KEY RESULTS All 14 patients had serological evidence and/or tissue evidence of immunological abnormality. Post-IVIG therapy, there was a significant improvement in symptoms scores for nausea, vomiting, early satiety, and abdominal pain. CONCLUSIONS AND INFERENCES Although limited by the absence of placebo group, the data illustrate the role of autoimmunity and neuromuscular evaluation in patients with gastroparesis and support the utility of a diagnostic trial of immunotherapy in an effort to improve therapeutic outcomes for such patients.
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Affiliation(s)
- M Ashat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - A Lewis
- Department of Internal Medicine, University of Louisville, Louisville, KY, USA
| | - H Liaquat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - A Stocker
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - L McElmurray
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - V Vedanarayanan
- Division of Neuromuscular Medicine, University of Mississippi, Oxford, MS, USA
| | - K Soota
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - T Howell
- GI Motility Clinic, Jewish Hospital, Louisville, KY, USA
| | - A Kedar
- Division of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - J Obert
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - T L Abell
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, Jewish Hospital GI Motility Clinic, University of Louisville, Louisville, KY, USA
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Balint B, Vincent A, Meinck HM, Irani SR, Bhatia KP. Movement disorders with neuronal antibodies: syndromic approach, genetic parallels and pathophysiology. Brain 2018; 141:13-36. [PMID: 29053777 PMCID: PMC5888977 DOI: 10.1093/brain/awx189] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/10/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
Movement disorders are a prominent and common feature in many autoantibody-associated neurological diseases, a group of potentially treatable conditions that can mimic infectious, metabolic or neurodegenerative disease. Certain movement disorders are likely to associate with certain autoantibodies; for example, the characteristic dyskinesias, chorea and dystonia associated with NMDAR antibodies, stiff person spectrum disorders with GAD, glycine receptor, amphiphysin or DPPX antibodies, specific paroxysmal dystonias with LGI1 antibodies, and cerebellar ataxia with various anti-neuronal antibodies. There are also less-recognized movement disorder presentations of antibody-related disease, and a considerable overlap between the clinical phenotypes and the associated antibody spectra. In this review, we first describe the antibodies associated with each syndrome, highlight distinctive clinical or radiological 'red flags', and suggest a syndromic approach based on the predominant movement disorder presentation, age, and associated features. We then examine the underlying immunopathophysiology, which may guide treatment decisions in these neuroimmunological disorders, and highlight the exceptional interface between neuronal antibodies and neurodegeneration, such as the tauopathy associated with IgLON5 antibodies. Moreover, we elaborate the emerging pathophysiological parallels between genetic movement disorders and immunological conditions, with proteins being either affected by mutations or targeted by autoantibodies. Hereditary hyperekplexia, for example, is caused by mutations of the alpha subunit of the glycine receptor leading to an infantile-onset disorder with exaggerated startle and stiffness, whereas antibodies targeting glycine receptors can induce acquired hyperekplexia. The spectrum of such immunological and genetic analogies also includes cerebellar ataxias and some encephalopathies. Lastly, we discuss how these pathophysiological considerations could reflect on possible future directions regarding antigen-specific immunotherapies or targeting the pathophysiological cascades downstream of the antibody effects.
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Affiliation(s)
- Bettina Balint
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Department of Neurology, University Hospital, Heidelberg, Germany
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Angela Vincent
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | | | - Sarosh R Irani
- Neuroimmunology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303952 DOI: 10.1097/pra.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303953 DOI: 10.1097/pra.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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Abstract
Autoimmune movement disorders are caused by an aberrant immune response to neural self-antigens. These disorders may be paraneoplastic, parainfectious, or (most commonly) idiopathic. The neurological presentations are diverse, and sometimes multifocal. Movement disorders can occur as part of the spectrum with phenotypes including chorea, myoclonus, ataxia, CNS hyperexcitability (including stiff-person syndrome), dystonia, and parkinsonism. Symptoms are subacute in onset and may have a fluctuating course. The best characterized disorders are unified by neural autoantibodies identified in serum or cerebrospinal fluid. The antibody specificity may predict the association with cancer and the response to immunotherapy. In this article, we review autoimmune-mediated movement disorders, associated cancers, diagnosis, and treatment.
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Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 5: Neurological auto-antibodies, discussion, flow chart, conclusions. Lung Cancer 2017; 111:164-175. [DOI: 10.1016/j.lungcan.2017.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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42
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Gadoth A, Pittock SJ, Dubey D, McKeon A, Britton JW, Schmeling JE, Smith A, Kotsenas AL, Watson RE, Lachance DH, Flanagan EP, Lennon VA, Klein CJ. Expanded phenotypes and outcomes among 256 LGI1/CASPR2-IgG-positive patients. Ann Neurol 2017. [PMID: 28628235 DOI: 10.1002/ana.24979] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe an expanded phenotypic spectrum and longitudinal outcome in 256 LGI1-IgG-seropositive and/or CASPR2-IgG-seropositive patients. METHODS Patients were identified through service neural autoantibody evaluation. Ninety-five had longitudinal follow-up (7-456 months; median = 35). RESULTS Among 3,910 patients tested, 196 were LGI1-IgG positive, 51 were CASPR2-IgG positive, and 9 were dual positive. Cerebrospinal fluid testing was less sensitive than serum testing, detecting only 24 of 38 (63%) LGI1-IgG-positive and 5 of 6 (83%) CASPR2-IgG-positive patients. LGI1-IgG-positive specimens had higher voltage-gated potassium channel-IgG immunoprecipitation values (0.33nmol/l, range = 0.02-5.14) than CASPR2-IgG-positive specimens (0.10nmol/l, range = 0.00-0.45, p < 0.001). Of patients presenting with pain or peripheral nervous system (PNS) manifestations, 39% were LGI1-IgG seropositive (7% had solely neuropathy or pain). Multivariate analysis identified age as the only significant predictor of central nervous system (CNS) versus PNS involvement (>50 years; odds ratio = 15, p < 0.001). Paroxysmal dizziness spells (PDS), a unique LGI1-IgG accompaniment (14% of patients), frequently delayed the diagnosis. T2-mesiotemporal hyperintensity was more common in LGI1-IgG-positive (41%) than in CASPR2-IgG-positive patients (p = 0.033). T1-bright basal ganglia were confined to LGI1-IgG-positive patients with faciobrachial-dystonic seizures (9 of 39, 31%). Cancer was found in 44% of LGI1-IgG/CASPR2-IgG dual seropositive patients (one-third thymoma). Response to initial immunotherapy was favorable in 97%; mean modified Rankin score was 3 (range = 1-5) at onset and 1.74 (range = 0-6) at last follow-up, with 9% having severe refractory disability, 20% being asymptomatic, 28% receiving immunotherapy, and 58% receiving antiepileptic medication. INTERPRETATION Older age is a strong predictor of CNS involvement in patients seropositive for CASPR2-IgG or LGI1-IgG. Pain, peripheral manifestations, and stereotypic paroxysmal dizziness spells are common with LGI1-IgG. Response to initial immunotherapy is often favorable, but some patients remain severely disabled, requiring long-term immunotherapy and/or antiepileptic medications. Ann Neurol 2017;82:79-92.
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Affiliation(s)
- Avi Gadoth
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Jeff W Britton
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - John E Schmeling
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Aurelia Smith
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | | | | | - Daniel H Lachance
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Christopher J Klein
- Neuroimmunology Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN
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LGI1 tunes intrinsic excitability by regulating the density of axonal Kv1 channels. Proc Natl Acad Sci U S A 2017; 114:7719-7724. [PMID: 28673977 DOI: 10.1073/pnas.1618656114] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Autosomal dominant epilepsy with auditory features results from mutations in leucine-rich glioma-inactivated 1 (LGI1), a soluble glycoprotein secreted by neurons. Animal models of LGI1 depletion display spontaneous seizures, however, the function of LGI1 and the mechanisms by which deficiency leads to epilepsy are unknown. We investigated the effects of pure recombinant LGI1 and genetic depletion on intrinsic excitability, in the absence of synaptic input, in hippocampal CA3 neurons, a classical focus for epileptogenesis. Our data indicate that LGI1 is expressed at the axonal initial segment and regulates action potential firing by setting the density of the axonal Kv1.1 channels that underlie dendrotoxin-sensitive D-type potassium current. LGI1 deficiency incurs a >50% down-regulation of the expression of Kv1.1 and Kv1.2 via a posttranscriptional mechanism, resulting in a reduction in the capacity of axonal D-type current to limit glutamate release, thus contributing to epileptogenesis.
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Stepp KA, Folker C, Tanzer M, Hayman J, Reynolds T, Mallory L. Autoimmune Voltage-Gated Potassium Channelopathy Presenting With Catecholamine Excess. Pediatr Neurol 2017; 72:86-89. [PMID: 28511811 DOI: 10.1016/j.pediatrneurol.2017.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/22/2017] [Accepted: 03/31/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autoimmune voltage-gated potassium channelopathies have been associated with a range of neurological presenting symptoms, including central, peripheral, and autonomic dysfunction. PATIENT DESCRIPTION We describe a 12-year-old boy who presented with nine months of pain, anxiety, and 30-pound weight loss. He was admitted for failure to thrive, then noted to be persistently hypertensive and tachycardic. Plasma metanephrines and urine metanephrines and catecholamines were elevated. Extensive investigation for causes of elevated catecholamines, such as hyperthyroidism or catecholamine-secreting tumor, was negative. A paraneoplastic panel was positive for voltage-gated potassium channel antibodies. Treatment with intravenous immunoglobulin and pulse methylprednisolone led to complete resolution of symptoms, weight gain, and normalization of vital signs and plasma metanephrines. CONCLUSION Voltage-gated potassium channel antibodies should be considered as part of the differential in patients presenting with elevated metanephrine and catecholamine secretion.
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Affiliation(s)
- K Amy Stepp
- Department of Pediatrics, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine.
| | - Christin Folker
- Department of Pediatrics, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine
| | - Marie Tanzer
- Department of Pediatric Nephrology, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine
| | - Jennifer Hayman
- Department of Pediatrics, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine
| | - Thomas Reynolds
- Department of Pediatric Neurology, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine
| | - Leah Mallory
- Department of Pediatrics, Maine Medical Center's Barbara Bush Children's Hospital, Portland, Maine
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Gonzalez Primomo SN, Blas L, Bertotti AC, Ameri C. Urinary manifestations in Isaacs's syndrome. Our experience in 8 cases. Neurourol Urodyn 2017; 37:496-500. [DOI: 10.1002/nau.23336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/03/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | - Leandro Blas
- Uroneurophysiology and Pelvic Floor Laboratory—German Hospital—C.A.B.A.Buenos AiresArgentina
| | - Alicia C. Bertotti
- Uroneurophysiology and Pelvic Floor Laboratory—German Hospital—C.A.B.A.Buenos AiresArgentina
| | - Carlos Ameri
- Uroneurophysiology and Pelvic Floor Laboratory—German Hospital—C.A.B.A.Buenos AiresArgentina
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Feyissa AM, López Chiriboga AS, Britton JW. Antiepileptic drug therapy in patients with autoimmune epilepsy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e353. [PMID: 28680914 PMCID: PMC5489139 DOI: 10.1212/nxi.0000000000000353] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/28/2017] [Indexed: 12/30/2022]
Abstract
Objective: We aimed to report the pattern of usage and efficacy of antiepileptic drugs (AEDs) in patients with autoimmune epilepsy (AE). Methods: We retrospectively studied the Mayo Clinic's electronic medical record of patients with AE in which seizures were the main presenting feature. Clinical data, including demographics, seizure characteristics, type of AED and immunotherapy used, presence of neural antibody, and treatment outcomes, were reviewed. Results: The medical records of 252 adult patients diagnosed with autoimmune encephalitis and paraneoplastic disorders were reviewed. Seizure was the initial presentation in 50 patients (20%). Serum and/or CSF autoantibodies were detected in 41 (82%) patients, and 38 (76%) patients had neural autoantibodies. The majority (n = 43, 86%) received at least 1 form of immunotherapy in combination with AEDs, while the remainder received AEDs alone. Twenty-seven patients (54%) became seizure free: 18 (36%) with immunotherapy, 5 (10%) with AEDs alone, and 4 (8%) with AEDs after immunotherapy failure. Levetiracetam was the most commonly used (42/50); however, it was associated with 0% seizure-free response. AED seizure-free responses occurred with carbamazepine (n = 3) [3/16, 18.8%], lacosamide (n = 3) [3/18, 16.6%] with phenytoin (n = 1) [1/8, 12.5%], or oxcarbazepine (n = 2) [2/11, 18.1%]. Regardless of the type of therapy, voltage-gated potassium channel-complex antibody–positive patients were more likely to become seizure free compared with glutamic acid decarboxylase 65 antibody–positive cases (12/17 vs 2/10, p = 0.0183). Conclusions: In select patients, AEDs alone were effective in controlling seizures. AEDs with sodium channel blocking properties resulted in seizure freedom in a few cases. Prospective studies are needed to clarify AED selection and to elucidate their immunomodulatory properties in AE.
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Affiliation(s)
- Anteneh M Feyissa
- Department of Neurology (A.M.F., A.S.L.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (J.W.B.), Mayo Clinic, Rochester, MN
| | - A Sebastian López Chiriboga
- Department of Neurology (A.M.F., A.S.L.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (J.W.B.), Mayo Clinic, Rochester, MN
| | - Jeffrey W Britton
- Department of Neurology (A.M.F., A.S.L.C.), Mayo Clinic, Jacksonville, FL; and Department of Neurology (J.W.B.), Mayo Clinic, Rochester, MN
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Fang Z, Yang Y, Chen X, Zhang W, Xie Y, Chen Y, Liu Z, Yuan W. Advances in Autoimmune Epilepsy Associated with Antibodies, Their Potential Pathogenic Molecular Mechanisms, and Current Recommended Immunotherapies. Front Immunol 2017; 8:395. [PMID: 28487693 PMCID: PMC5403900 DOI: 10.3389/fimmu.2017.00395] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/21/2017] [Indexed: 01/17/2023] Open
Abstract
In this comprehensive article, we present an overview of some most common autoimmune antibodies believed to be potentially pathogenic for autoimmune epilepsies and elaborate their pathogenic mode of action in molecular levels based on the existing knowledge. Findings of the studies of immunemodulatory treatments for epilepsy are also discussed, and guidelines for immunotherapy are sorted out. We aim to summarize the emerging understanding of different pathogenic mechanisms of autoantibodies and clinical immunotherapy regimens to open up therapeutic possibilities for future optimum therapy. We conclude that early diagnosis of autoimmune epilepsy is of great significance, as early immune treatments have useful disease-modifying effects on some epilepsies and can facilitate the recovery.
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Affiliation(s)
- Zhiwei Fang
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China.,School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Yunqi Yang
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China.,Zhiyuan College, Shanghai Jiao Tong University, Shanghai, China
| | - Xuan Chen
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Weiwang Zhang
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Yangmei Xie
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yinghui Chen
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Weien Yuan
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
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Platt MP, Agalliu D, Cutforth T. Hello from the Other Side: How Autoantibodies Circumvent the Blood-Brain Barrier in Autoimmune Encephalitis. Front Immunol 2017; 8:442. [PMID: 28484451 PMCID: PMC5399040 DOI: 10.3389/fimmu.2017.00442] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/30/2017] [Indexed: 12/11/2022] Open
Abstract
Antibodies against neuronal receptors and synaptic proteins are associated with autoimmune encephalitides (AE) that produce movement and psychiatric disorders. In order to exert their pathological effects on neural circuits, autoantibodies against central nervous system (CNS) targets must gain access to the brain and spinal cord by crossing the blood–brain barrier (BBB), a tightly regulated gateway formed by endothelial cells lining CNS blood vessels. To date, the pathogenic mechanisms that underlie autoantibody-triggered encephalitic syndromes are poorly understood, and how autoantibodies breach the barrier remains obscure for almost all AE syndromes. The relative importance of cellular versus humoral immune mechanisms for disease pathogenesis also remains largely unexplored. Here, we review the proposed triggers for various autoimmune encephalopathies and their animal models, as well as basic structural features of the BBB and how they differ among various CNS regions, a feature that likely underlies some regional aspects of autoimmune encephalitis pathogenesis. We then discuss the routes that antibodies and immune cells employ to enter the CNS and their implications for AE. Finally, we explore future therapeutic strategies that may either preserve or restore barrier function and thereby limit immune cell and autoantibody infiltration into the CNS. Recent mechanistic insights into CNS autoantibody entry indicate promising future directions for therapeutic intervention beyond current, short-lived therapies that eliminate circulating autoantibodies.
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Affiliation(s)
- Maryann P Platt
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA.,Department of Pharmacology, Columbia University Medical Center, New York, NY, USA.,Columbia Translational Neuroscience Initiative, Columbia University Medical Center, New York, NY, USA
| | - Tyler Cutforth
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.,Columbia Translational Neuroscience Initiative, Columbia University Medical Center, New York, NY, USA
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49
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Sweeney M, Galli J, McNally S, Tebo A, Haven T, Thulin P, Clardy SL. Delayed LGI1 seropositivity in voltage-gated potassium channel (VGKC)-complex antibody limbic encephalitis. BMJ Case Rep 2017; 2017:bcr-2016-218893. [PMID: 28432047 PMCID: PMC5534759 DOI: 10.1136/bcr-2016-218893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We utilise a clinical case to highlight why exclusion of voltage-gated potassium channel (VGKC)-complex autoantibody testing in serological evaluation of patients may delay or miss the diagnosis. A 68-year-old man presented with increasing involuntary movements consistent with faciobrachial dystonic seizures (FBDS). Initial evaluation demonstrated VGKC antibody seropositivity with leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) seronegativity. Aggressive immunotherapy with methylprednisolone and plasmapheresis was started early in the course of his presentation. Following treatment with immunotherapy, the patient demonstrated clinical improvement. Repeat serum evaluation 4 months posthospitalisation remained seropositive for VGKC-complex antibodies, with development of LGI1 autoantibody seropositivity. VGKC-complex and LGI1 antibodies remained positive 12 months posthospitalisation. Our findings suggest that clinical symptoms can predate the detection of the antibody. We conclude that when suspicion for autoimmune encephalitis is high in the setting of VGKC autoantibody positivity, regardless of LGI1 or CASPR2 seropositivity, early immunotherapy and repeat testing should be considered.
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Affiliation(s)
- Michael Sweeney
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan Galli
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Scott McNally
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Anne Tebo
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA.,Associated and Regional and University Pathologists Laboratory®, Salt Lake City, Utah, USA
| | - Thomas Haven
- Associated and Regional and University Pathologists Laboratory®, Salt Lake City, Utah, USA
| | - Perla Thulin
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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