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Jean M, Paidi R, Paidi G, Akhter S. Complexities in Managing Psychosis in a Patient With Stiff-Person Syndrome: A Case Report. Cureus 2024; 16:e52930. [PMID: 38406022 PMCID: PMC10893909 DOI: 10.7759/cureus.52930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Stiff-person syndrome (SPS) is an uncommon autoimmune neurological disorder marked by painful muscle stiffness, muscle spasms, and limb weakness. Neurological symptoms in SPS can mimic a psychogenic movement disorder in which symptoms are triggered by sudden movement and emotional distress, which might delay proper treatment. However, psychiatric symptoms are far less common, and there is limited understanding regarding the co-occurrence of psychiatric conditions. Psychiatric symptoms include nonspecific anxiety, agoraphobia, and depression, which can be triggered by sudden movement, noise, or emotional stress. This case report dives into the psychiatric manifestations seen in a patient with SPS. The case report focuses on a 42-year-old female with SPS, migraines, systemic lupus erythematosus, Sjogren's syndrome, and a psychiatric history of anorexia, depression, and anxiety. Her unique presentation underscored the necessity for a multidisciplinary approach to psychiatric care. The patient was evaluated and managed during her admission to the psychiatric unit for unspecified psychosis. Her course included a complicated medical evaluation for cardiovascular and neurologic symptoms and comprehensive psychiatric management. She manifested resistance to specific psychiatric medications and care strategies. She had atypical presentations, like sensory symptoms and left-sided chest pain. She exhibited paranoia and psychosis, which were managed with a combination of pharmacologic treatments, including aripiprazole. Psychotic symptoms were resolved upon discharge, with an emphasis on strict outpatient follow-up. This case report enhances our understanding of the clinical nuances associated with SPS and its intersection with psychiatric symptoms. The objective of this case report is to detail the diagnostic and therapeutic complexities of managing psychosis in a patient with SPS, along with a pre-existing complex medical and psychiatric profile, and to contribute to a deeper understanding of SPS and associated psychiatric conditions and more effective management strategies.
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Affiliation(s)
- Marie Jean
- Department of Psychiatry, Garnet Health Medical Center, Middletown, USA
| | - Ramprasad Paidi
- Internal Medicine, S. Nijalingappa Medical College, Bangalore, IND
| | - Gokul Paidi
- Internal Medicine, Abrazo Community Health Network, Glendale, USA
| | - Sayma Akhter
- School of Medicine, Touro College of Osteopathic Medicine, Middletown, USA
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Almudhi A, Gabr SA. Associations between glutamic acid decarboxylase antibodies, oxidative stress markers, and cognitive capacity in adolescents who stutter. Saudi J Biol Sci 2023; 30:103580. [PMID: 36844638 PMCID: PMC9943924 DOI: 10.1016/j.sjbs.2023.103580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/04/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
In this study, we amid to evaluate the correlation between the change in the expressed levels of anti-GAD antibodies titers, oxidative stress markers, cytokines markers, and cognitive capacity in adolescents with mild stuttering. Eighty participants (60 male/20 female) with the age range of 10-18 years with moderate stutteringparticipated in this study. To assess the stuttering and cognitive function, stutteringseverity instrument (SSI-4; 4th edit.)and the LOTCA-7 scores assessment were applied respectively in all subjects. In addition, serum GAD antibodies, cytokines like TNF-α, CRP,and IL-6 withtotal antioxidant capacity and nitric oxide as oxidative stress markers were estimated using calorimetry and immunoassay techniques.The results showed that good cognitive capacity was reported in about 56.25 % of the study population (n = 45) with a 117.52 ± 6.3 mean LOTCA-7 score. However, abnormal cognitive function was identified in 43.75 % of the study population (n = 35); they were categorized into moderate (score 62-92, n = 35), and poor (score 31-62; n = 10). There were significant associations between cognitive capacity reported and all biomarkers. The expression of GAD antibodies is significantly associated with the degree of cognitive capacity among students with stuttering. Significant association with the reduction (P = 0.01) in LOTCA-7 score domains, particularly orientation, thinking operations, attention, and concentration among students with variable cognitive capacity compared to controls. In addition, the expressed higher GAD antibodies in students with moderate and poor cognitive capacity showed to be significantly correlated with both elevated concentrations of cytokines; TNF-α, CRP, and IL-6, and the reduction of TAC and nitric oxide (NO) respectively. This study concludes that abnormality of cognitive capacity showed to be associated with higher expression of GAD antibodies, cytokines, and oxidative stress in school students with moderate stuttering.
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Affiliation(s)
- Abdulaziz Almudhi
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia,Speech Language Pathology Unit, King Khalid University, Abha 61481, Saudi Arabia,Corresponding author at: Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia.
| | - Sami A. Gabr
- Department of Anatomy and Embryology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt
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Martin Prieto J, Rouco Axpe I, Moreno Estébanez A, Rodríguez-Antigüedad Zarrantz A. Rapid cognitive decline associated with anti-glutamic acid decarboxylase antibodies: A case repot. Neurologia 2022; 37:151-152. [PMID: 34034919 DOI: 10.1016/j.nrl.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- J Martin Prieto
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, España.
| | - I Rouco Axpe
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, España
| | - A Moreno Estébanez
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, España
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Martin Prieto J, Rouco Axpe I, Moreno Estébanez A, Rodríguez-Antigüedad Zarrantz A. Rapid cognitive decline associated with anti-glutamic acid decarboxylase antibodies: a case report. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:151-152. [PMID: 34969633 DOI: 10.1016/j.nrleng.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- J Martin Prieto
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain.
| | - I Rouco Axpe
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain
| | - A Moreno Estébanez
- Servicio de Neurología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain
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Kershenbaum A, Zandi MS, Perez J. Catatonia with glycine receptor antibodies: Heads up? Schizophr Res 2021; 235:7-8. [PMID: 34274798 DOI: 10.1016/j.schres.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Anne Kershenbaum
- CAMEO Early Intervention in Psychosis Service, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK; Department of Psychiatry, University of Cambridge, Cambridge, Herchel Smith Building, Cambridge, UK
| | - Michael S Zandi
- National Hospital for Neurology and Neurosurgery, UCL Queen Square Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jesus Perez
- CAMEO Early Intervention in Psychosis Service, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK; Department of Psychiatry, University of Cambridge, Cambridge, Herchel Smith Building, Cambridge, UK; Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK; National Institute for Health Research (NIHR) Applied Research Collaboration East of England, Cambridge, UK.
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Caffrey D, Finn CT, Song SM, Burton F, Arsan C. Stiff-Person Syndrome and Psychiatric Comorbidities: A Systematic Review. J Acad Consult Liaison Psychiatry 2020; 62:3-13. [PMID: 33183848 DOI: 10.1016/j.psym.2020.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stiff-person syndrome (SPS) is a rare autoimmune neurologic disease characterized by painful rigidity and muscle spasms. Patients with SPS may present with psychiatric symptoms, and little is known about the presence of psychiatric comorbidities. OBJECTIVE The objective of this study was to provide an overview of the association between SPS and psychiatric illnesses. METHODS The protocol is registered in PROSPERO (Registration ID CRD42020159354). Peer-reviewed articles on adults with SPS and psychiatric comorbidities published before May 26, 2020, were selected by 2 independent reviewers. Qualitative summary data and relative risk of psychiatric disorders in patients with SPS compared with the general population and multiple sclerosis were calculated. RESULTS After screening 909 articles, 52 full texts were assessed for eligibility and 27 were ultimately included, 5 of which were selected for quantitative analysis. Although limited by small sample sizes leading to large confidence intervals, the relative risk of any psychiatric comorbidity in SPS was higher than that of the general population, ranging from estimates of 6.09 (95% confidence interval: 4.09, 9.08) to 11.25 (95% confidence interval: 3.27, 38.66). There was no statistically significant difference in the risk of any psychiatric comorbidity between SPS and multiple sclerosis. The review also highlighted delays in SPS diagnosis, often related to misattribution of symptoms as being solely secondary to a psychiatric cause. CONCLUSIONS The higher risk of psychiatric comorbidities emphasizes the important role of psychiatrists in recognizing the symptoms of SPS to reach timely diagnosis and treatment. The presence of psychiatric symptoms should support rather than delay the diagnosis of SPS.
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Affiliation(s)
- Deirdre Caffrey
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH; Department of Psychiatry, Columbia University Irving Medical Center, New York, NY.
| | - Christine T Finn
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Seoho Michael Song
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Frederick Burton
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Cybele Arsan
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH; Department of Psychiatry, Keck Hospital of University of Southern California, Los Angeles, CA
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Wright SL. Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review. Adv Ther 2020; 37:2604-2619. [PMID: 32378069 PMCID: PMC7467435 DOI: 10.1007/s12325-020-01354-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. METHODS A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author's personal files. RESULTS BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2-4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20-100% of those who take these agents for more than a month. CONCLUSIONS BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12-18 months or longer.
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Affiliation(s)
- Steven L Wright
- Alliance for Benzodiazepine Best Practices, Littleton, CO, USA.
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Patel K, Stummer L, Patel K. Stiff-person syndrome in a patient with comorbid bipolar and panic disorders: A case report and literature review. Ment Health Clin 2020; 10:95-99. [PMID: 32420007 PMCID: PMC7213949 DOI: 10.9740/mhc.2020.05.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Stiff-person syndrome (SPS) is a neurologic disorder characterized by muscle stiffness, rigidity, and muscle spasms, and it can increase a patient's risk for falls. It is recognized as a rare disease with limited clinical guidelines to manage the condition and its symptoms. Currently, there is even less clinical guidance for the management of common comorbid conditions in these patients. This patient case report aims to evaluate the efficacy of various medications for symptom management in a patient with SPS and comorbid psychiatric disorders, specifically bipolar I and panic disorder. Throughout the patient's course of treatment, various medications were trialed, including fluoxetine, hydroxyzine, valproic acid, propranolol, and clonazepam. Ultimately, fluoxetine, hydroxyzine, and propranolol were discontinued due to adverse drug reactions and incomplete symptom resolution. The patient's bipolar I disorder was adequately managed with valproic acid. Once the clonazepam was changed from as-needed to scheduled dosing, the patient's panic disorder and anxiety-triggered spasms were well controlled. The efficacy of benzodiazepines, specifically high doses of diazepam, in alleviating muscle spasms and anxiety in SPS has been demonstrated in the literature. Case reports including patients with SPS that are prescribed selective serotonin reuptake inhibitors provide controversial evidence as some studies report exacerbation of SPS symptoms with prolonged use. As this case report and literature review suggest, patients with SPS and comorbid panic disorder and anxiety-triggered spasms may benefit from the use of benzodiazepines. The use of other medication classes for the treatment of other comorbid psychiatric disorders in a patient with SPS is lacking evidence.
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El-Abassi R, Soliman MY, Villemarette-Pittman N, England JD. SPS: Understanding the complexity. J Neurol Sci 2019; 404:137-149. [PMID: 31377632 DOI: 10.1016/j.jns.2019.06.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/31/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stiff-person syndrome (SPS), first described in 1956 by Moersch and Woltman, is a progressive autoimmune disorder with core features of chronic fluctuating progressive truncal and limb rigidity and painful muscle spasms leading to gait difficulties, falls and an appearance that resembles tin soldiers. The syndrome is a rare, highly disabling disorder of the central nervous and frequently results in significant disability. Understanding of the etiology, clinical spectrum, diagnostic workup and therapeutic modalities for this painful and disabling disorder has vastly evolved over the past few years with more confidence in classifying and treating the patients. The purpose of this review is to increase the awareness, early detection, and treatment of this disabling disease. METHOD PubMed was searched, all date inclusive, using the following phrases: stiff person syndrome,anti-Glutamic acid decarboxylase (Anti-GAD) antibody syndrome, Progressive encephalomyelitis with rigidity and myoclonus (PERM), and Paraneoplastic Stiff Person syndrome. No filters or restrictions were used. A total of 888 articles were identified. RESULTS The results were narrowed to 190 citations after excluding non-English and duplicate reports. Clinical presentation, laboratory testing, treatment, and prognosis were categorized and summarized. DISCUSSION In this article we will discuss the epidemiology, presentation and classification. Explain the pathophysiology of SPS and the autoimmune mechanisms involved. Discuss the diagnostic approach and treatments available, as well as, the prognosis and outcome.
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Affiliation(s)
- Rima El-Abassi
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA.
| | - Michael Y Soliman
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
| | | | - John D England
- Department of Neurology, Louisiana State University School of medicine, New Orleans, USA
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No SW, Im IK, Kim DH. Stiff Person Syndrome With Evidence of Nonspecific Focal Myositis Secondary to Sustained Muscle Contraction: A Case Report. PM R 2018; 10:1426-1430. [PMID: 29705167 DOI: 10.1016/j.pmrj.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/23/2018] [Accepted: 04/02/2018] [Indexed: 11/18/2022]
Abstract
Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by progressive muscular rigidity and spasms that affect axial and limb muscles. There have been a few reports that patients with SPS had evidences of polymyositis. There have been no clear explanations about the characteristics of polymyositis in SPS. We report the case of a 36-year-old woman with SPS in association with nonspecific focal myositis secondary to sustained muscle contraction. She presented with stiffness and pain in her extremities, and diazepam and baclofen were ineffective. With immunotherapy, her serum creatinine kinase levels reduced; however, her clinical symptoms progressively worsened. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Seung-Wook No
- Department of Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea(∗)
| | - Il-Kyu Im
- Department of Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea(†)
| | - Du Hwan Kim
- Department of Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu 41931, South Korea(‡).
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Redefining progressive encephalomyelitis with rigidity and myoclonus after the discovery of antibodies to glycine receptors. Curr Opin Neurol 2017; 30:310-316. [DOI: 10.1097/wco.0000000000000450] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Alghadir AH, Gabr SA, Al-Eisa ES. Assessment of the effects of glutamic acid decarboxylase antibodies and trace elements on cognitive performance in older adults. Clin Interv Aging 2015; 10:1901-7. [PMID: 26664103 PMCID: PMC4671766 DOI: 10.2147/cia.s95974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Homeostatic imbalance of trace elements such as iron (Fe), copper (Cu), and zinc (Zn) demonstrated adverse effects on brain function among older adults. Objective The present study aimed to investigate the effects of trace elements and the presence of anti-glutamic acid decarboxylase antibodies (GADAs) in human cognitive abilities among healthy older adults. Methods A total of 100 healthy subjects (65 males, 35 females; age range; 64–96 years) were recruited for this study. Based on Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) score, the participants were classified according to cognitive performance into normal (n=45), moderate (n=30), and severe (n=25). Cognitive functioning, leisure-time physical activity (LTPA), serum trace elements – Fe, Cu, Zn, Zn/Cu, and GADAs were assessed using LOTCA battery, pre-validated physical activity (PA) questionnaire, atomic absorption, and immunoassay techniques, respectively. Results Approximately 45% of the study population (n=45) had normal distribution of cognitive function and 55% of the study population (n=55) had abnormal cognitive function; they were classified into moderate (score 62–92) and severe (score 31–62). There was a significant reduction in the level of Zn and Zn/Cu ratio along with an increase in the level of Fe, Cu, and anti-GADAs in subjects of severe (P=0.01) and moderate (P=0.01) cognitive performance. LOTCA-cognitive scores correlated positively with sex, HbA1c, Fe, Cu, Zn, and Zn/Cu ratio, and negatively with age, PA, body mass index, and anti-GADAs. Significant inter-correlation was reported between serum trace element concentrations and anti-GADAs which suggest producing a cognitive decline via oxidative and neural damage mechanism. Conclusion This study found significant associations among trace elements, anti-GADAs, and cognitive function in older adults. The homeostatic balance of trace elements should be recommended among older adults for better cognitive performance.
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Affiliation(s)
- Ahmad H Alghadir
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Sami A Gabr
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia ; Department of Anatomy, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Einas S Al-Eisa
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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Baizabal-Carvallo JF, Jankovic J. Stiff-person syndrome: insights into a complex autoimmune disorder. J Neurol Neurosurg Psychiatry 2015; 86:840-8. [PMID: 25511790 DOI: 10.1136/jnnp-2014-309201] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 11/21/2014] [Indexed: 02/06/2023]
Abstract
Stiff-person syndrome (SPS) is characterised by progressive rigidity and muscle spasms affecting the axial and limb muscles. Since its initial description in 1956, marked progress has been made in the clinical characterisation, understanding of pathogenesis and therapy of this disorder. SPS can be classified according to the clinical presentation into classic SPS and SPS variants: focal or segmental-SPS, jerking-SPS and progressive encephalomyelitis with rigidity and myoclonus. Most patients with SPS have antibodies directed against the glutamic acid decarboxylase, the rate-limiting enzyme for the production of the inhibitory neurotransmitter γ-aminobutyric acid (GABA). Antibodies directed against GABA(A) receptor-associated protein, and the glycine-α1 receptor can also be observed. Paraneoplastic SPS is commonly associated with antiamphiphysin antibodies and breast cancer. Treatment of SPS with drugs that increase the GABAergic tone combined with immunotherapy can improve the neurological manifestations of these patients. The prognosis, however, is unpredictable and spontaneous remissions are unlikely.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
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Takagi M, Yamasaki H, Endo K, Yamada T, Kaneko K, Oka Y, Mori E. Cognitive decline in a patient with anti-glutamic acid decarboxylase autoimmunity; case report. BMC Neurol 2011; 11:156. [PMID: 22188660 PMCID: PMC3292981 DOI: 10.1186/1471-2377-11-156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 12/21/2011] [Indexed: 12/02/2022] Open
Abstract
Background Glutamic acid decarboxylase (GAD) is the rate-limiting enzyme for producing γ-aminobutyric acid, and it has been suggested that antibodies against GAD play a role in neurological conditions and type 1 diabetes. However, it is not known whether dementia appears as the sole neurological manifestation associated with anti-GAD antibodies in the central nervous system. Case presentation We describe the clinical, neuropsychological, and neuroradiological findings of a 73-year-old female with cognitive dysfunction and type 1A diabetes. Observation and neuropsychological studies revealed linguistic problems, short-term memory disturbance, and frontal dysfunction. MRI showed no significant lesion except for confluent small T2-hyperintensity areas localized in the left basal ganglia. 18F-fluorodeoxy glucose-positron emission tomography (FDG-PET) and 123I-N-isopropyl-p-iodoamphetamine-single photon emission computed tomography (IMP-SPECT) studies showed bifrontal hypometabolism and hypoperfusion. Immunomodulating therapy with intravenous high-dose immunoglobulin resulted in no remission of the cognitive symptoms. Conclusions Cognitive dysfunction may develop as an isolated neurological manifestation in association with type 1A diabetes and anti-GAD autoimmunity. A systematic study with extensive neuropsychological assessment is indicated in patients with type 1 diabetes and anti-GAD autoimmunity.
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Affiliation(s)
- Masahito Takagi
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8574, Japan.
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Cuturic M, Harden LM, Kannaday MH, Campbell NN, Harding RK. Stiff-person syndrome presenting as eating disorder: a case report. Int J Eat Disord 2011; 44:284-6. [PMID: 20186723 DOI: 10.1002/eat.20794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To report a case of a 35-year-old female initially treated for anorexia nervosa who was found to have Stiff-Person Syndrome (SPS). METHOD Case report. RESULTS The patient reported panic attacks at meal times that were found to consist of tetanic contractions of the axial musculature. Swallowing initiated reflexive painful muscle spasms that consequently resulted in cibophobia and significant weight loss. Her serum tested positive for anti-glutamic acid decarboxylase antibodies, and she subsequently improved with appropriate treatment for SPS. DISCUSSION SPS has not been previously reported in the context of eating disorders, although it has been linked to other psychiatric disorders. Often the psychiatrist may be the first physician to diagnose SPS. We present this case to alert practitioners to the potential co-morbidity and symptom overlap between SPS and eating disorders, to aid in early recognition and appropriate treatment of this rare illness.
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Affiliation(s)
- Miroslav Cuturic
- South Carolina Department of Mental Health, and University of South Carolina School of Medicine, Columbia, South Carolina, USA.
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Fleischman D, Madan G, Zesiewicz TA, Fleischman M. Stiff-person syndrome: commonly mistaken for hysterical paralysis. Clin Neurol Neurosurg 2009; 111:644. [PMID: 19473753 DOI: 10.1016/j.clineuro.2009.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2009] [Accepted: 04/27/2009] [Indexed: 10/20/2022]
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Teggi R, Piccioni LO, Martino G, Bellini C, Bussi M. Stiff-person syndrome with acute recurrent peripheral vertigo: possible evidence of gamma aminobutyric acid as a neurotransmitter in the vestibular periphery. The Journal of Laryngology & Otology 2007; 122:636-8. [PMID: 17666138 DOI: 10.1017/s0022215107000205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We report a case of a 58-year-old man suffering from stiff-person syndrome and recurrent peripheral vertigo. METHOD A case report and a review of the recent literature on stiff-person syndrome are presented. RESULTS The patient presented with recurrent episodes of vertigo with a pure peripheral pattern and with concomitant episodes of burning muscle pain, muscle twitching, weight gain and fatigue, worsening with tension or stress that also occurred in periods without vertigo. Cochlear examinations only showed presbyacusis-like hearing loss. The diagnosis of stiff-person syndrome was made with electromyographic examination and from findings in the blood and cerebrospinal fluid of high titres of anti-glutamic acid decarboxylase (GAD67) autoantibodies. In a two-year follow-up period, therapy for stiff-person syndrome abolished episodes of both stiffness and vertigo. CONCLUSION As far as we know, no other clinical case of acute vestibular damage with a possible correlation with anti-glutamic acid decarboxylase antibodies has been described. Peripheral vertigo possibly related to a lack of gamma aminobutyric acid underlines a possible role of gamma aminobutyric acid as a neurotransmitter in the peripheral vestibular system.
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Affiliation(s)
- R Teggi
- ENT Department, San Raffaele Hospital, Vita-Salute University, Milan, Italy.
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Dinnerstein E, Collins D, Berman SA. A Patient With Post-traumatic Stress Disorder Developing Stiff Person Syndrome. Cogn Behav Neurol 2007; 20:136-7. [PMID: 17558259 DOI: 10.1097/wnn.0b013e31804c701e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Stiff person syndrome (SPS) is an uncommon disorder characterized by progressive muscle stiffness, rigidity, and axial muscle spasms. It is presumed to be an autoimmune process, with glutamic acid decarboxylase antibodies present in most cases. Here, we present a case report of a patient diagnosed with post-traumatic stress disorder (PTSD) acquired by sexual trauma and by exposure to the severely wounded soldiers she attended as a nurse. Subsequently, she developed SPS confirmed by serology. The possibility of an association between PTSD and SPS is theorized, given their relationship to the GABAergic system. Further studies examining the relation between PTSD and SPS should be initiated.
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Affiliation(s)
- Eric Dinnerstein
- Section of Neurology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
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Abstract
Classic stiff-person syndrome (SPS) is a clinically diagnosed disease characterized by axial and often appendicular rigidity with lumbar hyperlordosis and painful spasms. Supportive data include increased glutamic acid decarboxylase autoantibody titers more than 20 nmol/L, a needle electromyography with continuous motor unit activity in at least one axial muscle, and normal MRI and cerebrospinal fluid studies. Variants of SPS include those with focal limb dysfunction (stiff-limb syndrome), encephalomyelitis ("SPS plus"), and those associated with paraneoplastic autoantibodies. Although the precise mechanism is unknown, an autoimmune etiology for SPS is proposed, based on its association with autoantibodies and other autoimmune diseases and its response to immunomodulatory therapy. The cornerstone of treatment consists of symptomatic care with benzodiazepines and/or baclofen. Other neuromodulators include antiepileptic medications and muscle relaxants. Continued disability despite first-line therapy should prompt consideration of agents aimed at immunomodulation and immunosuppression. Intravenous immunoglobulin is one of the few agents to be evaluated in a double-blind, randomized controlled trial. Other options include steroids, plasma exchange, and chemotherapy agents.
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Affiliation(s)
- Juliana Lockman
- Ted M. Burns, MD University of Virginia, Department of Neurology, PO Box 800394, Charlottesville, VA 22908, USA.
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Potter K. Physical Therapy During In-Patient Rehabilitation for a Patient with Stiff-Person Syndrome. J Neurol Phys Ther 2006; 30:28-38. [PMID: 16630369 DOI: 10.1097/01.npt.0000282147.18446.b8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Patients with Stiff-Person Syndrome (SPS) typically show stiffness and spasms, primarily of the trunk and proximal lower extremities. The purpose of this case report is to provide an overview of SPS and a description of the specific physical therapy management strategies used during a brief inpatient rehabilitation stay for a patient with SPS, illustrating the use of the patient/client management model in the Guide to Physical Therapist Practice. CASE DESCRIPTION The patient was a 33-year-old with a 3- year history of SPS. He spent 10 days in an in-patient rehabilitation hospital where he received physical therapy daily. The initial examination revealed impairments of pain, range of motion, reflex integrity, and motor function, along with abnormalities of posture, balance, and function. The procedural interventions included therapeutic exercise and functional retraining. Stretching exercises were categorized according to their priority and level of difficulty to accommodate for the patient's varying symptoms, and relaxation exercises aimed to reduce the severity of the patient's spasms. The functional retraining program included transfer and progressive gait training. OUTCOMES The patient showed improvements in ankle range of motion, posture, and gait (distance, speed, and independence), despite continued problems with stiffness, spasms, and pain. DISCUSSION Physical therapists working with patients with SPS have challenges related to the paucity of information in the literature. The chronic, progressive, and variable nature of SPS indicates the need for life-long management, with the inclusion of an exercise program that can be adjusted accordingly, given the frequently changing symptoms experienced by the patient. As is shown with this case, it appears that physical therapy can improve function and some of the impairments associated with SPS.
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Abstract
BACKGROUND Stiff-person syndrome (SPS) is a rare neurologic disorder with autoimmune features. It is characterized by progressive, severe muscle rigidity or stiffness most prominently affecting the spine and lower extremities. REVIEW SUMMARY Superimposed muscle spasms result in simultaneous contraction of agonist and antagonist muscles which are detectable by electromyography (EMG) and relieved by administration of benzodiazepines. The exacerbation of SPS by emotional stressors often results in the referral of these patients for psychiatric assessment although this was more common before the discovery of an association with antibodies to glutamic acid decarboxylase (GAD antibodies). Formerly known as stiff-man syndrome, the female to male ratio is 2:1 and the principle paraneoplastic variant is associated with breast cancer. Although rare, this is a disease of middle age that severely curtails the functional capacity of those it strikes. It is frequently associated with diabetes and other autoimmune diseases. IVIg is recently demonstrated to be effective in the treatment of SPS; diazepam remains useful in managing the symptoms. CONCLUSIONS This article summarizes the history of SPS, describes important clinical features, discusses management, touches upon areas of uncertainty, and postulates some avenues for research.
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Affiliation(s)
- Beth Brianna Murinson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA.
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22
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Abstract
OBJECTIVE To investigate systematically the rate and type of phobia in stiff man syndrome and its variants, and to compare patients with stiff man syndrome with and without phobia for sociodemographic and neurological characteristics. METHODS 43 consecutive patients with stiff man syndrome referred to a university department of neurology were assessed using the anxiety disorders interview schedule, revised (ADIS-R), a structured diagnostic interview for anxiety disorders, in addition to a full clinical neurological and psychiatric assessment. RESULTS 19 patients (44.2%) developed task specific phobia--that is, fear and avoidance of situations difficult to master owing to the motor symptoms of stiff man syndrome (such as crossing streets). Three further patients (7%) had subthreshold phobia--that is, phobic anxiety without avoidance. There were no significant differences between patients with and without phobia in terms of age, illness duration, type of stiff man syndrome, antibody status, or frequency of falls. Patients with phobia were more likely to present with exaggerated startle responses and to have an initial misdiagnosis of psychogenic movement disorder. CONCLUSIONS Specific phobia is a frequent non-motor symptom of stiff man syndrome. Early recognition is an important aid to correct diagnosis. The aetiology of phobia in stiff man syndrome is unknown. There is no evidence of a direct pathogenic role of autoantibodies directed against glutamic acid decarboxylase in the development of phobia.
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Affiliation(s)
- P Henningsen
- Department of Psychosomatic Medicine, University Hospital, Thibautstrasse 2, 69115 Heidelberg, Germany.
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Dinkel K, Rickert M, Möller G, Adamski J, Meinck HM, Richter W. Stiff-man syndrome: identification of 17 beta-hydroxysteroid dehydrogenase type 4 as a novel 80-kDa antineuronal antigen. J Neuroimmunol 2002; 130:184-93. [PMID: 12225901 DOI: 10.1016/s0165-5728(02)00218-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Stiff-man syndrome (SMS) is a rare autoimmune disorder of the central nervous system associated with autoantibodies to glutamate decarboxylase (GAD). We isolated five brain-reactive human monoclonal antibodies, with reactivity distinct from GAD, from peripheral blood of a patient newly diagnosed with SMS. Two antibodies reacted with both Purkinje cells and ependymal cells, and precipitated an 80-kDa protein from rat neuronal primary cultures, which was also recognized by 12% (3/25) of SMS sera and 13% (2/15) of SMS cerebrospinal fluid (CSF) samples. The corresponding antigen was identified as 17 beta-hydroxysteroid dehydrogenase type 4 and may represent a possible novel target of autoimmunity in SMS.
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Affiliation(s)
- Klaus Dinkel
- Department of Orthopedic Surgery, University of Heidelberg, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
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Abstract
Stiff person syndrome (SPS) is a rare, chronic disorder characterized by painful spasm and stiffness. We investigated the quality of life (QoL) in SPS patients, and identified factors associated with impairment in patients' QoL. Twenty-four SPS patients (10 men, 14 women; mean age +/- S.D., 52.6 +/- 9.5 years) completed the medical outcomes study Short Form health survey (SF-36), the Beck Depression Inventory (BDI), and a questionnaire asking for sociodemographic and clinical details. Extent of the disease was assessed using a distribution of stiffness score. SPS patients showed markedly reduced mean scores for all dimensions of the SF-36 when compared to norms from the general population of the United Kingdom. QoL scores showed a strong correlation with the extent of the disease. Depression was a common finding; 14 of 24 patients had depressive symptoms as evidenced by the BDI. There was a significant and strong correlation between the BDI score and several SF-36 subscores. This is the first study to address QoL in patients with SPS. We have shown that SPS has a significant impact on patients' reported QoL. The association between depression and QoL highlights the importance of recognizing and treating depression in SPS.
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Affiliation(s)
- Willibald Gerschlager
- Sobell Department of Motor Neurosciences and Movement Disorders, Institute of Neurology, Queen Square, London, United Kingdom.
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Kiriakos CR, Franco KN. Stiff-man syndrome: a case report and review of the literature. PSYCHOSOMATICS 2002; 43:243-4. [PMID: 12075042 DOI: 10.1176/appi.psy.43.3.243] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Carol R Kiriakos
- Department of Psychiatry and Psychology, Cleveland Clinic Foundation, Ohio, USA
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Abstract
Stiff-person syndrome (SPS) is a rare disease of severe progressive muscle stiffness in the spine and lower extremities with superimposed muscle spasms triggered by external stimuli. Patients with SPS are often referred for psychiatric evaluation and the psychiatrist may be the first to diagnosis SPS. Psychosocial stressors often precede the first manifestations of the disease; depression, anxiety, and alcohol abuse are comorbid illnesses. The identification of an association with antibodies to glutamic acid decarboxylase (GAD) was invaluable for definitively establishing a pathological basis for the disease; antibodies to amphiphysin and gephyrin are also found in cases of SPS but at much lower frequencies. Whether the antibodies inhibit GAD activity in vivo, target GAD-expressing neurons for immune-mediated destruction, are part of a wider immune process, or are merely a marker for destruction of GAD-expressing neurons by an independent neurodegenerative process is not yet clear. Both electromyography and the detection of GAD antibodies are useful in establishing a diagnosis of SPS. Treatment of SPS includes the use of immunomodulating therapies (plasmapheresis and intravenous immunoglobulins) and symptomatic treatment with benzodiazepines and baclofen. The use of tricyclic antidepressants and rapid withdrawal from therapy should be avoided.
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Affiliation(s)
- B B Murinson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21289, USA.
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Abstract
The study of SMS, a rare disease, has resulted in a better understanding of a more common disorder, IDDM, and has allowed investigators to gain insights into the molecular mechanisms of autoimmunity. Many unanswered questions remain, such as the specific site of disease activity in SMS, both at the bedside (cortex, brain stem, or spinal cord) and at the bench (neuronal cytoplasma or synapse). The association of SMS with neoplastic disease and the development of autonomicdysfunction are not understood. The next decade may provide answers to these puzzling issues.
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Affiliation(s)
- S M Helfgott
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Black JL, Lamke GT, Walikonis JE. Serologic survey of adult patients with obsessive-compulsive disorder for neuron-specific and other autoantibodies. Psychiatry Res 1998; 81:371-80. [PMID: 9925188 DOI: 10.1016/s0165-1781(98)00120-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A subset of patients with pediatric onset obsessive-compulsive disorder (OCD) and tic syndromes (e.g. Tourette's syndrome) have symptom onset or exacerbation associated with infection. Some of these patients have been demonstrated to have antineuronal antibodies reactive with nuclei of the basal ganglion. It has been hypothesized that these patients have an immune process initiated by infection that affects the basal ganglion and causes obsessive-compulsive symptoms. The term pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) has been coined to describe those patients with evidence of recent group A beta hemolytic streptococcal infection. We tested the serum from 13 adult patients with obsessive-compulsive disorder for panels of autoantibodies that serve as markers of autoimmunity in the practice of neurology and internal medicine. We investigated the frequency of neuron-specific autoantibodies [N-type and P/Q-type voltage-gated calcium channel antibodies, type 1 Purkinje cell antibodies, types 1 and 2 antineuronal nuclear antibodies, amphiphysin antibodies, and glutamic acid decarboxylase (65 kDa) antibodies], other organ-specific autoantibodies (muscle acetylcholine receptor-binding antibodies, striated muscle antibodies, thyroid microsomal and thyroglobulin antibodies), and non-organ-specific autoantibodies (antinuclear antibodies, antimitochondrial antibodies, and smooth muscle antibodies) to determine if any of these antibodies might serve as a serological marker for adult OCD or yield evidence of an autoimmune diathesis. Although most of our subjects had onset of OCD before 19 years of age (N=8) or before puberty (N=4), the study revealed no humoral evidence of autoimmunity involving the neuron-, organ-, and non-organ-specific antibodies that we assayed.
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Affiliation(s)
- J L Black
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
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