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Madigan V, Zhang Y, Raghavan R, Wilkinson ME, Faure G, Puccio E, Segel M, Lash B, Macrae RK, Zhang F. Human paraneoplastic antigen Ma2 (PNMA2) forms icosahedral capsids that can be engineered for mRNA delivery. Proc Natl Acad Sci U S A 2024; 121:e2307812120. [PMID: 38437549 PMCID: PMC10945824 DOI: 10.1073/pnas.2307812120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/20/2023] [Indexed: 03/06/2024] Open
Abstract
A number of endogenous genes in the human genome encode retroviral gag-like proteins, which were domesticated from ancient retroelements. The paraneoplastic Ma antigen (PNMA) family members encode a gag-like capsid domain, but their ability to assemble as capsids and traffic between cells remains mostly uncharacterized. Here, we systematically investigate human PNMA proteins and find that a number of PNMAs are secreted by human cells. We determine that PNMA2 forms icosahedral capsids efficiently but does not naturally encapsidate nucleic acids. We resolve the cryoelectron microscopy (cryo-EM) structure of PNMA2 and leverage the structure to design engineered PNMA2 (ePNMA2) particles with RNA packaging abilities. Recombinantly purified ePNMA2 proteins package mRNA molecules into icosahedral capsids and can function as delivery vehicles in mammalian cell lines, demonstrating the potential for engineered endogenous capsids as a nucleic acid therapy delivery modality.
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Affiliation(s)
- Victoria Madigan
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Yugang Zhang
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Rumya Raghavan
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Max E. Wilkinson
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Guilhem Faure
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Elena Puccio
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Michael Segel
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Blake Lash
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Rhiannon K. Macrae
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
| | - Feng Zhang
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA02142
- McGovern Institute for Brain Research at Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA02139
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA02139
- HHMI, Cambridge, MA02139
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Xu J, Erlendsson S, Singh M, Holling GA, Regier M, Ibiricu I, Einstein J, Hantak MP, Day GS, Piquet AL, Smith TL, Clardy SL, Whiteley AM, Feschotte C, Briggs JAG, Shepherd JD. PNMA2 forms immunogenic non-enveloped virus-like capsids associated with paraneoplastic neurological syndrome. Cell 2024; 187:831-845.e19. [PMID: 38301645 PMCID: PMC10922747 DOI: 10.1016/j.cell.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/20/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
The paraneoplastic Ma antigen (PNMA) proteins are associated with cancer-induced paraneoplastic syndromes that present with an autoimmune response and neurological symptoms. Why PNMA proteins are associated with this severe autoimmune disease is unclear. PNMA genes are predominantly expressed in the central nervous system and are ectopically expressed in some tumors. We show that PNMA2, which has been co-opted from a Ty3 retrotransposon, encodes a protein that is released from cells as non-enveloped virus-like capsids. Recombinant PNMA2 capsids injected into mice induce autoantibodies that preferentially bind external "spike" PNMA2 capsid epitopes, whereas a capsid-assembly-defective PNMA2 protein is not immunogenic. PNMA2 autoantibodies in cerebrospinal fluid of patients with anti-Ma2 paraneoplastic disease show similar preferential binding to spike capsid epitopes. PNMA2 capsid-injected mice develop learning and memory deficits. These observations suggest that PNMA2 capsids act as an extracellular antigen, capable of generating an autoimmune response that results in neurological deficits.
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Affiliation(s)
- Junjie Xu
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Simon Erlendsson
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK; Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Manvendra Singh
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - G Aaron Holling
- Department of Biochemistry, University of Colorado Boulder, Boulder, CO, USA
| | - Matthew Regier
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Iosune Ibiricu
- Department of Cell and Virus Structure, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Jenifer Einstein
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Michael P Hantak
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Amanda L Piquet
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Tammy L Smith
- Department of Neurology, University of Utah and George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah and George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | | | - Cédric Feschotte
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - John A G Briggs
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK; Department of Cell and Virus Structure, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Jason D Shepherd
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA.
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3
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Graus F. Clinical approach to diagnosis of paraneoplastic neurologic syndromes. Handb Clin Neurol 2024; 200:79-96. [PMID: 38494298 DOI: 10.1016/b978-0-12-823912-4.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The correct diagnosis of a paraneoplastic neurologic syndrome (PNS) first requires the identification of the syndrome as one of those defined as high-risk (previously called classical) or intermediate-risk for cancer in the 2021 PNS diagnostic criteria. Testing for neuronal antibodies should be restricted to these syndromes as indiscriminate request decreases the diagnostic value of the antibodies. Identifying onconeural (high-risk for cancer) or intermediate-risk for cancer antibodies supports the paraneoplastic diagnosis and mandates the search for an underlying cancer. Tumor screening must follow the published guidelines. Repeated screening is indicated in neurologic syndromes with onconeural antibodies and patients with high-risk for cancer neurologic syndromes unless they present neuronal antibodies which are not associated with cancer. Neuronal antibodies should be screened by immunohistochemistry and confirmed by immunoblot (intracellular antigens) or cell-based assay (CBA) (surface antigens). Positive results only by immunoblot or CBA should be taken with caution. Although the 2021 diagnostic criteria for PNS do not capture all PNS, as they do not allow to diagnose definite PNS neurologic syndromes without neuronal antibodies, the updated criteria represent a step forward to differentiate true PNS from neurologic syndromes that coincide in time with cancer diagnosis without having a pathogenic link.
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Affiliation(s)
- Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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4
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Dalmau J. Changing landscape in the field of paraneoplastic neurology: Personal perspectives over a 35-year career. Handb Clin Neurol 2024; 200:11-32. [PMID: 38494272 DOI: 10.1016/b978-0-12-823912-4.00013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes are a group of rare disorders that have fascinated neurologists for more than a century. The discovery in the 1980s that many of these disorders occurred in association with antibodies against neuronal proteins revived the interest for these diseases. This chapter first traces the history of the paraneoplastic neurologic syndromes during the era that preceded the discovery of immune mechanisms and then reviews the immunologic period during which many of these syndromes were found to be associated with antibodies against intracellular onconeuronal proteins and pathogenic cytotoxic T-cell mechanisms. Alongside these developments, investigations on the antibody-mediated disorders of the peripheral nervous system, such as the myasthenic syndromes or neuromyotonia, provided suggestions for the study of the central nervous system (CNS) syndromes. These converging areas of research culminated with the groundbreaking discovery of a new category of CNS disorders mediated by antibodies against neuronal surface proteins or receptors. These disorders are not always paraneoplastic, and the understanding of these syndromes and mechanisms has changed the landscape of neurology and neurosciences.
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Affiliation(s)
- Josep Dalmau
- IDIBAPS-Hospital Clinic, University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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5
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Kadish R, Clardy SL. Epidemiology of paraneoplastic neurologic syndromes. Handb Clin Neurol 2024; 200:57-77. [PMID: 38494297 DOI: 10.1016/b978-0-12-823912-4.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS), initially depicted as seemingly cryptic remote manifestations of malignancy, were first described clinically in the early 20th century, with pathophysiologic correlates becoming better elucidated in the latter half of the century. There remain many questions not only about the pathophysiology but also regarding the epidemiology of these conditions. The continuous discovery of novel autoantigens and related neurologic disease has broadened the association in classical PNS to include conditions such as paraneoplastic cerebellar degeneration. It has also brought into focus several other neurologic syndromes with a putative neoplastic association. These conditions are overall rare, making it difficult to capture large numbers of patients to study, and raising the question of whether incidence is increasing over time or improved identification is driving the increased numbers of cases. With the rise and increasing use of immunotherapy for cancer treatment, the incidence of these conditions is additionally expected to rise and may present with various clinical symptoms. As we enter an era of clinical trial intervention in these conditions, much work is needed to capture more granular data on population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, and gender to optimize care and clinical trial planning.
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Affiliation(s)
- Robert Kadish
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States.
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6
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Abbatemarco JR, Vedeler CA, Greenlee JE. Paraneoplastic cerebellar and brainstem disorders. Handb Clin Neurol 2024; 200:173-191. [PMID: 38494276 DOI: 10.1016/b978-0-12-823912-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic cerebellar and brainstem disorders are a heterogeneous group that requires prompt recognition and treatment to help prevent irreversible neurologic injury. Paraneoplastic cerebellar degeneration is best characterized by Yo antibodies in patients with breast or ovarian cancer. Tr (DNER) antibodies in patients with Hodgkin lymphoma can also present with a pure cerebellar syndrome and is one of the few paraneoplastic syndromes found with hematological malignancy. Opsoclonus-myoclonus-ataxia syndrome presents in both pediatric and adult patients with characteristic clinical findings. Other paraneoplastic brainstem syndromes are associated with Ma2 and Hu antibodies, which can cause widespread neurologic dysfunction. The differential for these disorders is broad and also includes pharmacological side effects, infection or postinfectious processes, and neurodegenerative diseases. Although these immune-mediated disorders have been known for many years, mechanisms of pathogenesis are still unclear, and optimal treatment has not been established.
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Affiliation(s)
- Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States; Department of Neurology, University of Utah, Salt Lake City, UT, United States
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7
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Hammami MB, Rezk M, Dubey D. Paraneoplastic neurologic syndrome and autoantibody accompaniments of germ cell tumors. Handb Clin Neurol 2024; 200:431-445. [PMID: 38494295 DOI: 10.1016/b978-0-12-823912-4.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNSs) are a group of diseases affecting the central and/or peripheral nervous system caused by immune-mediated processes directed toward antigens with shared expression in tumor and neural tissue. Germ cell tumors (GCTs) are associated with PNSs with varied clinical phenotypes. Early diagnosis of PNS is vital to potentially uncover and treat underlying tumors, improving the chances of recovery, and preventing permanent neurologic complications. In this chapter, we outline the pathophysiology and epidemiology of PNS. We briefly provide a summary of GCTs in males and females. We review the neural-specific autoantibodies and PNSs associated with GCTs and their clinical and radiologic accompaniments. We also provide an overview of the treatment and prognosis of these disorders.
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Affiliation(s)
- M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mohamed Rezk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Quinot V, Höftberger R. Pathogenesis and immunopathology of paraneoplastic disorders. Handb Clin Neurol 2024; 200:33-54. [PMID: 38494287 DOI: 10.1016/b978-0-12-823912-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic neurologic syndromes (PNS) represent a rare group of immune-mediated complications associated with an underlying tumor. Ectopic protein expression in neoplastic cells or an aberrant immune regulation in the course of hematooncologic diseases or thymomas trigger an autoimmune response that may affect any part of the central and/or peripheral nervous system. Recent advances in drug therapies as well as novel animal models and neuropathologic studies have led to further insights on the immune pathomechanisms of PNS. Although the syndromes share common paths in pathogenesis, they may differ in the disease course, prognosis, and therapy targets, depending on the localization and type of antibody epitope. Neuropathologic hallmarks of PNS associated with antibodies directed against intracellular epitopes are characterized by T cell-dominated inflammation, reactive gliosis including microglial nodules, and neuronal degeneration. By contrast, the neuropathology of cell surface antibody-mediated PNS strongly depends on the targeted antigen and varies from B cell/plasma cell-dominated inflammation and well-preserved neurons together with a reduced expression of the target antigen in anti-NMDAR encephalitis to irreversible Purkinje cell loss in anti-P/Q-type VGCC antibody-associated paraneoplastic cerebellar degeneration. The understanding of different pathomechanisms in PNS is important because they strongly correspond with therapy response and prognosis, and should guide treatment decisions.
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Affiliation(s)
- Valérie Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria.
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Waters P, Mills JR, Fox H. Evolution of methods to detect paraneoplastic antibodies. Handb Clin Neurol 2024; 200:113-130. [PMID: 38494273 DOI: 10.1016/b978-0-12-823912-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
An adaptive immune response in less than 1% of people who develop cancer produces antibodies against neuronal proteins. These antibodies can be associated with paraneoplastic syndromes, and their accurate detection should instigate a search for a specific cancer. Over the years, multiple systems, from indirect immunofluorescence to live cell-based assays, have been developed to identify these antibodies. As the specific antigens were identified, high throughput, multi-antigen substrates such as line blots and ELISAs were developed for clinical laboratories. However, the evolution of assays required to identify antibodies to membrane targets has shone a light on the importance of antigen conformation for antibody detection. This chapter discusses the early antibody assays used to detect antibodies to nuclear and cytosolic targets and how new approaches are required to detect antibodies to membrane targets. The chapter presents recent data that support international recommendations against the sole use of line blots for antibody detection and highlights a new antigen-specific approach that appears promising for the detection of submembrane targets.
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Affiliation(s)
- Patrick Waters
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Hannah Fox
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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10
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Alsuwaidi S, Kamalboor H, Khairi T, Almadani A. Anti-Ma2 encephalitis in a phenotypic female with XY gonadal dysgenesis: A case report. Epilepsy Behav Rep 2023; 24:100623. [PMID: 37854277 PMCID: PMC10579952 DOI: 10.1016/j.ebr.2023.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023] Open
Abstract
Anti-Ma2 encephalitis is an autoimmune disorder that typically involves the brainstem, limbic system, and diencephalon. It can be paraneoplastic and is more common in males. We describe an unusual presentation of anti-Ma2 encephalitis in a patient with an XY chromosome and a female phenotype. She experienced various neurological symptoms, including olfactory hallucinations, episodic nausea, per-ictal water drinking, and hypersomnolence, that were poorly controlled by antiseizure medications (ASMs) and immunotherapy. Brain MRI showed abnormalities in right medial temporal and frontal regions, and blood tests detected anti-Ma2 antibodies. Screening for malignancies yielded no tumors. Pelvic CT showed bilateral inguinal masses and the absence of a uterus, while genetic studies revealed an XY karyotype. Surgical removal of the masses, shown to be primitive gonads, offered temporary relief, necessitating ongoing ASMs and immunotherapy.
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11
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Chiu D, Rhee J, Gonzalez Castro LN. Diagnosis and Treatment of Paraneoplastic Neurologic Syndromes. Antibodies (Basel) 2023; 12:50. [PMID: 37606434 PMCID: PMC10443237 DOI: 10.3390/antib12030050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Paraneoplastic antibody syndromes result from the anti-tumor antibody response against normal antigens ectopically expressed by tumor cells. Although this antibody response plays an important role in helping clear a nascent or established tumor, the engagement of antigens expressed in healthy tissues can lead to complex clinical syndromes with challenging diagnosis and management. The majority of known paraneoplastic antibody syndromes have been found to affect the central and peripheral nervous system. The present review provides an update on the pathophysiology of paraneoplastic neurologic syndromes, as well as recommendations for their diagnosis and treatment.
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Affiliation(s)
- Daniel Chiu
- Department of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
| | - John Rhee
- Department of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA
| | - L. Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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12
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Ashish S, Raj M, Islam M, Zhuang E. Paraneoplastic Necrotizing Myopathy Associated With Metastatic Colon Cancer: A Case Report. Cureus 2023; 15:e36538. [PMID: 37090332 PMCID: PMC10121228 DOI: 10.7759/cureus.36538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Necrotizing myopathy (NM) as a paraneoplastic process in malignancies is a rare phenomenon. An association of inflammatory myositis with malignancy and chemotherapies has been reported in several case reports. Here, we present an unusual case of paraneoplastic NM associated with metastatic colon cancer.
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Affiliation(s)
- Sethi Ashish
- Medical Oncology, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Moses Raj
- Hematology and Medical Oncology, Allegheny Health Network, Pittsburgh, USA
| | - Mohammad Islam
- Hematology and Medical Oncology, Allegheny Health Network, Pittsburgh, USA
| | - Eric Zhuang
- Hematology and Medical Oncology, Allegheny Health Network, Pittsburgh, USA
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Xu J, Erlendsson S, Singh M, Regier M, Ibiricu I, Day GS, Piquet AL, Clardy SL, Feschotte C, Briggs JAG, Shepherd JD. PNMA2 forms non-enveloped virus-like capsids that trigger paraneoplastic neurological syndrome. bioRxiv 2023:2023.02.09.527862. [PMID: 36798413 PMCID: PMC9934673 DOI: 10.1101/2023.02.09.527862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The paraneoplastic Ma antigen (PNMA) genes are associated with cancer-induced paraneoplastic syndromes that present with neurological symptoms and autoantibody production. How PNMA proteins trigger a severe autoimmune disease is unclear. PNMA genes are predominately expressed in the central nervous system with little known functions but are ectopically expressed in some tumors. Here, we show that PNMA2 is derived from a Ty3 retrotransposon that encodes a protein which forms virus-like capsids released from cells as non-enveloped particles. Recombinant PNMA2 capsids injected into mice induce a robust autoimmune reaction with significant generation of autoantibodies that preferentially bind external "spike" PNMA2 capsid epitopes, while capsid-assembly-defective PNMA2 protein is not immunogenic. PNMA2 autoantibodies present in cerebrospinal fluid of patients with anti-Ma2 paraneoplastic neurologic disease show similar preferential binding to PNMA2 "spike" capsid epitopes. These observations suggest that PNMA2 capsids released from tumors trigger an autoimmune response that underlies Ma2 paraneoplastic neurological syndrome.
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Affiliation(s)
- Junjie Xu
- Department of Neurobiology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Simon Erlendsson
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Manvendra Singh
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - Matthew Regier
- Department of Neurobiology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Iosune Ibiricu
- Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Gregory S. Day
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Amanda L. Piquet
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Stacey L. Clardy
- Department of Neurology, Spencer Fox Eccles School of Medicine, University of Utah, and George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - Cedric Feschotte
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - John A. G. Briggs
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK
- Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Jason D. Shepherd
- Department of Neurobiology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
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Daguano Gastaldi V, Bh Wilke J, Weidinger CA, Walter C, Barnkothe N, Teegen B, Luessi F, Stöcker W, Lühder F, Begemann M, Zipp F, Nave KA, Ehrenreich H. Factors predisposing to humoral autoimmunity against brain-antigens in health and disease: Analysis of 49 autoantibodies in over 7000 subjects. Brain Behav Immun 2023; 108:135-147. [PMID: 36323361 DOI: 10.1016/j.bbi.2022.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/24/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Circulating autoantibodies (AB) against brain-antigens, often deemed pathological, receive increasing attention. We assessed predispositions and seroprevalence/characteristics of 49 AB in > 7000 individuals. METHODS Exploratory cross-sectional cohort study, investigating deeply phenotyped neuropsychiatric patients and healthy individuals of GRAS Data Collection for presence/characteristics of 49 brain-directed serum-AB. Predispositions were evaluated through GWAS of NMDAR1-AB carriers, analyses of immune check-point genotypes, APOE4 status, neurotrauma. Chi-square, Fisher's exact tests and logistic regression analyses were used. RESULTS Study of N = 7025 subjects (55.8 % male; 41 ± 16 years) revealed N = 1133 (16.13 %) carriers of any AB against 49 defined brain-antigens. Overall, age dependence of seroprevalence (OR = 1.018/year; 95 % CI [1.015-1.022]) emerged, but no disease association, neither general nor with neuropsychiatric subgroups. Males had higher AB seroprevalence (OR = 1.303; 95 % CI [1.144-1.486]). Immunoglobulin class (N for IgM:462; IgA:487; IgG:477) and titers were similar. Abundant were NMDAR1-AB (7.7 %). Low seroprevalence (1.25 %-0.02 %) was seen for most AB (e.g., amphiphysin, KCNA2, ARHGAP26, GFAP, CASPR2, MOG, Homer-3, KCNA1, GLRA1b, GAD65). Non-detectable were others. GWAS of NMDAR1-AB carriers revealed three genome-wide significant SNPs, two intergenic, one in TENM3, previously autoimmune disease-associated. Targeted analysis of immune check-point genotypes (CTLA4, PD1, PD-L1) uncovered effects on humoral anti-brain autoimmunity (OR = 1.55; 95 % CI [1.058-2.271]) and disease likelihood (OR = 1.43; 95 % CI [1.032-1.985]). APOE4 carriers (∼19 %) had lower seropositivity (OR = 0.766; 95 % CI [0.625-0.933]). Neurotrauma predisposed to NMDAR1-AB seroprevalence (IgM: OR = 1.599; 95 % CI [1.022-2.468]). CONCLUSIONS Humoral autoimmunity against brain-antigens, frequent across health and disease, is predicted by age, gender, genetic predisposition, and brain injury. Seroprevalence, immunoglobulin class, or titers do not predict disease.
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Affiliation(s)
- Vinicius Daguano Gastaldi
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Justus Bh Wilke
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Cosima A Weidinger
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Carolin Walter
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Nadine Barnkothe
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Bianca Teegen
- Institute for Experimental Immunology, Affiliated to Euroimmun, Lübeck, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine‑Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Winfried Stöcker
- Institute for Experimental Immunology, Affiliated to Euroimmun, Lübeck, Germany
| | - Fred Lühder
- Institute of Neuroimmunology and Multiple Sclerosis Research, University Medical Center, of the Georg August University, Göttingen, Germany
| | - Martin Begemann
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine‑Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Klaus-Armin Nave
- Department of Neurogenetics, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany
| | - Hannelore Ehrenreich
- Clinical Neuroscience, Max Planck Institute for Multidisciplinary Sciences, City Campus, Göttingen, Germany.
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15
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Fortunato F, Giugno A, Sammarra I, Labate A, Gambardella A. Epilepsy, Immunity and Neuropsychiatric Disorders. Curr Neuropharmacol 2023; 21:1714-1735. [PMID: 35794773 PMCID: PMC10514543 DOI: 10.2174/1570159x20666220706094651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.
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Affiliation(s)
- Francesco Fortunato
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Giugno
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Ilaria Sammarra
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Angelo Labate
- BIOMORF Department, Neurology Unit, University of Messina, Messina, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
- Institute of Molecular Bioimaging and Physiology, National Research Council, I-88100 Catanzaro, Italy
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16
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Younger DS. Paraneoplastic motor disorders. Handb Clin Neurol 2023; 196:231-250. [PMID: 37620071 DOI: 10.1016/b978-0-323-98817-9.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Paraneoplastic neurological disorders (PNDs) are heterogeneous clinicopathologic syndromes that occur throughout the neuraxis resulting from damage to organs or tissues remote from the site of a malignant neoplasm or its metastases. The discordance between severe neurological disability and even an indolent malignancy suggests an underlying neuroimmunologic host immune response that inflicts nervous tissue damage while inhibiting malignant tumor growth. Motor system involvement, like other symptoms and signs, is associated with focal or diffuse involvement of the brain, spinal cord, peripheral nerve, neuromuscular junction or muscle, alone or in combination due to an underlying neuroimmune and neuroinflammatory process targeting neural-specific antigens. Unrecognized and therefore untreated, PNDs are often lethal making early detection and aggressive treatment of paramount importance. While the combination of clinical symptoms and signs, and analysis of detailed body and neuroimaging, clinical neurophysiology and electrodiagnostic studies, and tumor and nervous system tissue biopsies are all vitally important, the certain diagnosis of a PND rests with the discovery of a corresponding neural-specific paraneoplastic autoantibody in the blood and/or spinal cerebrospinal fluid.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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17
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Komandla SR, Vankadari K, Milap M, V H, Kandadai RM. 18F-FDG PET/CT Findings in a Rare Case of Paraneoplastic Vestibulocerebellar Syndrome Associated With Isolated Antiamphiphysin Antibodies. Clin Nucl Med 2022; 47:e125-e128. [PMID: 34392286 DOI: 10.1097/rlu.0000000000003868] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Paraneoplastic cerebellar degeneration (PCD) is an immune-mediated neurological disease characterized by adaptive immune response against onconeural antigens physiologically expressed in the cerebellum. It is characterized by presence of highly specific onconeural autoantibodies such as anti-Yo, anti-Hu, anti-Ri, and anti-Ma2 in the serum and cerebrospinal fluid as diagnostic biomarkers. Antiamphiphysin autoantibody-related paraneoplastic encephalitis is a less commonly seen autoimmune neurological disorder usually presenting as stiff person syndrome. We present an unusual case of isolated antiamphiphysin antibody-related PCD presenting as vestibulocerebellar syndrome with associated sensorineural hearing loss and sensory neuropathy. FDG PET helped in topographical localization of brain lesion along with early detection of extragonadal germ cell tumor in the retroperitoneum.
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Affiliation(s)
| | | | | | - Hemanth V
- Surgical Oncology, Yashoda Hospital, Secunderabad
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18
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Greenlee JE, Carlson NG, Abbatemarco JR, Herdlevær I, Clardy SL, Vedeler CA. Paraneoplastic and Other Autoimmune Encephalitides: Antineuronal Antibodies, T Lymphocytes, and Questions of Pathogenesis. Front Neurol 2022; 12:744653. [PMID: 35111121 PMCID: PMC8801577 DOI: 10.3389/fneur.2021.744653] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/26/2021] [Indexed: 01/14/2023] Open
Abstract
Autoimmune and paraneoplastic encephalitides represent an increasingly recognized cause of devastating human illness as well as an emerging area of neurological injury associated with immune checkpoint inhibitors. Two groups of antibodies have been detected in affected patients. Antibodies in the first group are directed against neuronal cell surface membrane proteins and are exemplified by antibodies directed against the N-methyl-D-aspartate receptor (anti-NMDAR), found in patients with autoimmune encephalitis, and antibodies directed against the leucine-rich glioma-inactivated 1 protein (anti-LGI1), associated with faciobrachial dystonic seizures and limbic encephalitis. Antibodies in this group produce non-lethal neuronal dysfunction, and their associated conditions often respond to treatment. Antibodies in the second group, as exemplified by anti-Yo antibody, found in patients with rapidly progressive cerebellar syndrome, and anti-Hu antibody, associated with encephalomyelitis, react with intracellular neuronal antigens. These antibodies are characteristically found in patients with underlying malignancy, and neurological impairment is the result of neuronal death. Within the last few years, major advances have been made in understanding the pathogenesis of neurological disorders associated with antibodies against neuronal cell surface antigens. In contrast, the events that lead to neuronal death in conditions associated with antibodies directed against intracellular antigens, such as anti-Yo and anti-Hu, remain poorly understood, and the respective roles of antibodies and T lymphocytes in causing neuronal injury have not been defined in an animal model. In this review, we discuss current knowledge of these two groups of antibodies in terms of their discovery, how they arise, the interaction of both types of antibodies with their molecular targets, and the attempts that have been made to reproduce human neuronal injury in tissue culture models and experimental animals. We then discuss the emerging area of autoimmune neuronal injury associated with immune checkpoint inhibitors and the implications of current research for the treatment of affected patients.
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Affiliation(s)
- John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Noel G Carlson
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Geriatric Research, Education, and Clinical Center (GRECC), George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurobiology, University of Utah, Salt Lake City, UT, United States
| | - Justin R Abbatemarco
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Ida Herdlevær
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stacey L Clardy
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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19
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Abstract
Limbic encephalitis (LE) is a clinical syndrome defined by subacutely evolving limbic signs and symptoms with structural and functional evidence of mediotemporal damage in the absence of a better explanation than an autoimmune (or paraneoplastic) cause. There are features common to all forms of LE. In recent years, antibody(ab)-defined subtypes have been established. They are distinct regarding underlying pathophysiologic processes, clinical and magnetic resonance imaging courses, cerebrospinal fluid signatures, treatment responsivity, and likelihood of a chronic course. With immunotherapy, LE with abs against surface antigens has a better outcome than LE with abs to intracellular antigens. Diagnostic and treatment challenges are, on the one hand, to avoid overlooking and undertreatment and, on the other hand, to avoid overdiagnoses and overtreatment. LE can be conceptualized as a model disease for the consequences of new onset mediotemporal damage by different mechanisms in adult life. It may be studied as an example of mediotemporal epileptogenesis.
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Affiliation(s)
- Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Bielefeld University, Bielefeld, Germany; Laboratory Krone, Bad Salzuflen, Germany.
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20
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Abstract
Paraneoplastic neurological syndromes (PNS) are the immune-mediated effects of a remote cancer and are characterised by an autoantibody response against antigens expressed by the tumour. Classically, well-characterised 'onconeuronal' antibodies target intracellular antigens and hence cannot access their antigens across intact cell membranes. The pathogenic mediators are likely to be neuronal-specific T cells. There is a variable response to immunotherapies and the clinical syndrome helps to direct the search for a specific set of tumours. By contrast, many newly emerging autoantibodies with oncological associations target cell surface epitopes and can exert direct pathogenic effects on both the central and peripheral nervous systems. Patients with these cell-surface directed autoantibodies often clearly respond to immunotherapies. Overall, the clinical, serological and oncological features in an individual patient helps determine the clinical relevance of the syndrome and hence guide its management. We summarise current knowledge and a practical approach to the investigation, diagnosis, treatment and outcomes of patients with suspected PNS.
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Affiliation(s)
- Sophie Binks
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Uy
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.,Department of Medicine (Division of Neurology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerome Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hopital Neurologique, Lyon, France.,SynatAc Team, Institute NeuroMyoGene INSERM U1217/CNRS UMR 5310, Universite de Lyon, Universit Claude Bernard Lyon 1, Lyon, France
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK .,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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21
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Yin D, Chen S, Liu J. Sleep Disturbances in Autoimmune Neurologic Diseases: Manifestation and Pathophysiology. Front Neurosci 2021; 15:687536. [PMID: 34421519 PMCID: PMC8377735 DOI: 10.3389/fnins.2021.687536] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/19/2021] [Indexed: 01/12/2023] Open
Abstract
Autoimmune neurologic diseases are a new category of immune-mediated disease demonstrating a widely varied spectrum of clinical manifestations. Recently, sleep disturbances in patients with autoimmune neurologic diseases have been reported to have an immense negative impact on the quality of life. Excessive daytime sleep, rapid eye movement sleep behavior disorder (RBD), and narcolepsy are the most frequent sleep disorders associated with autoimmune neurologic diseases. Sleep disturbances might be the initial symptoms of disease or persist throughout the course of the disease. In this review, we have discussed sleep disturbances in different autoimmune neurologic diseases and their potential pathophysiological mechanisms.
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Affiliation(s)
- Dou Yin
- Department of Neurology, Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Chen
- Department of Neurology, Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Liu
- Department of Neurology, Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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22
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Ahn SJ, Lee HS, Lee WJ, Chu K. Low-dose interleukin-2 as a novel therapeutic option for refractory paraneoplastic neurologic syndrome: a case of chronic relapsing anti-Ma2/Ta paraneoplastic myeloradiculopathy. Encephalitis 2021; 1:79-84. [PMID: 37469846 PMCID: PMC10295880 DOI: 10.47936/encephalitis.2021.00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 07/21/2023] Open
Abstract
Paraneoplastic neurologic syndromes (PNS) caused by anti-Ma2/Ta antibodies have diverse presentations. Myeloradiculopathy is one anti-Ma2/Ta-associated PNS manifestation. We report the case of a patient with chronic relapsing anti-Ma2/Ta paraneoplastic myeloradiculopathy. The patient was successfully treated with low-dose human recombinant interleukin-2, despite having chronic relapsing symptoms and a refractory response to conventional immunotherapy.
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Affiliation(s)
- Seon-Jae Ahn
- Center for Hospital Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Sang Lee
- Center for Hospital Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo-Jin Lee
- Center for Hospital Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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23
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Chevalier K, Noel N, Benoudiba F, Chrétien P, Hacein-Bey-Abina S, Lambotte O. Anti-Ma2 antibody encephalitis associated with Sjogren's syndrome. Rev Med Interne 2021; 42:575-8. [PMID: 34052049 DOI: 10.1016/j.revmed.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 03/28/2021] [Accepted: 05/09/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Onconeuronal antibodies directed against intracellular antigens are strongly associated with paraneoplastic syndromes and their detection in the absence of cancer is unusual. We herein report a case of anti-Ma2 encephalitis associated with Sjogren's syndrome (SS). CASE REPORT An 81-year-old woman followed for a cutaneous lupus with vasculitis associated with SS presented a flare of her disease with neurological worsening including walking difficulty, hypersialorrhea and dysphagia. A paraneoplastic origin of the symptoms was suspected and anti-Ma2 antibodies were positive in serum. The search for an underlying neoplasia was negative. The diagnosis of anti-Ma2 encephalitis secondary to a SS was made. In the literature, the association of anti-Ma2 encephalitis and SS has been previously reported twice. Cases of patients with other onconeuronal antibodies associated with SS have been also reported. Anti-Ma2 encephalitis is a rare condition with a wide spectrum of symptoms associated with a cancer in more than 90% of the cases. Anti-Ma2 encephalitis has also been described after the use of immune check points inhibitors underscoring the role of autoimmunity in its pathogenesis. CONCLUSION Anti-Ma2 encephalitis is essentially associated with neoplasia but can occur in Sjogren's syndrome.
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24
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Dubey D, Kryzer T, Guo Y, Clarkson B, Cheville JC, Costello BA, Leibovich BC, Algeciras-Schimnich A, Lucchinnetti C, Hammami MB, Knight AM, Howe C, Lennon VA, McKeon A, Pittock SJ. Leucine Zipper 4 Autoantibody: A Novel Germ Cell Tumor and Paraneoplastic Biomarker. Ann Neurol 2021; 89:1001-1010. [PMID: 33583072 DOI: 10.1002/ana.26050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study was undertaken to describe a novel biomarker of germ cell tumor and associated paraneoplastic neurological syndrome (PNS). METHODS Archival sera from patients with germ cell tumor-associated PNS were evaluated. We identified a common autoantigen in a human testicular cancer cell line (TCam-2) by Western blot and mass spectrometry. Its identity was confirmed by recombinant-protein Western blot, enzyme-linked immunosorbent assay (ELISA), and cell-based assay. Autoantibody specificity was confirmed by analyzing assorted control sera/cerebrospinal fluid. RESULTS Leucine zipper 4 (LUZP4)-immunoglobulin G (IgG) was detected in 28 patients' sera, 26 of whom (93%) were men. The median age at neurological symptom onset was 45 years (range = 28-84). Median titer (ELISA) was 1:300 (1:50 to >1:6,400, normal value < 1:50). Coexistent kelchlike protein 11-IgG was identified in 18 cases (64%). The most common presenting phenotype was rhombencephalitis (17/28, 61%). Other presentations included limbic encephalitis (n = 5, 18%), seizures and/or encephalitis (n = 2, 7%), and motor neuronopathy/polyradiculopathy (n = 4, 14%). The most common malignancy among cancer-evaluated PNS patients was seminoma (21/27, 78%). Nine of the 21 seminomas detected by whole-body fluorodeoxyglucose positron emission tomography scan (43%) were extratesticular. Both female patients had ovarian teratoma. Regressed testicular germ cell tumors were found in 4 patients. Exposure of T-cell-dendritic-cell cocultures from chronic immunosuppression-naïve LUZP4-IgG-seropositive patients to recombinant LUZP4 protein evoked a marked increase in CD69 expression on both CD4+ and CD8+ T cells when compared to vehicle-exposed and healthy control cultures. INTERPRETATION LUZP4-IgG represents a novel serological biomarker of PNS and has high predictive value for germ cell tumors. The demonstrated antigen-specific T-cell responses support a CD8+ T-cell-mediated cytotoxic paraneoplastic and antitumor potential. ANN NEUROL 2021;89:1001-1010.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Thomas Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Benjamin Clarkson
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - John C Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | | | | | | | - Claudia Lucchinnetti
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - M Bakri Hammami
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | - Andrew M Knight
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY
| | - Charles Howe
- Department of Neurology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Vanda A Lennon
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY.,Department of Immunology, Mayo Clinic, Rochester, NY
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, NY.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, NY.,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, NY
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25
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Jitprapaikulsan J, Paul P, Thakolwiboon S, Mittal SO, Pittock SJ, Dubey D. Paraneoplastic neurological syndrome: an evolving story. Neurooncol Pract 2021; 8:362-374. [PMID: 34277016 DOI: 10.1093/nop/npab002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Paraneoplastic neurological syndrome (PNS) comprises a group of neurological disorders that result from a misguided immune response to the nervous system triggered by a distant tumor. These disorders frequently manifest before the diagnosis of the underlying neoplasm. Since the first reported case in 1888 by Oppenheim, the knowledge in this area has evolved rapidly. Several classic PNS have been described, such as limbic encephalitis, paraneoplastic cerebellar degeneration, encephalomyelitis, opsoclonus-myoclonus, sensory neuronopathy, Lambert-Eaton Myasthenic syndrome, and chronic gastrointestinal dysmotility. It is now recognized that PNS can have varied nonclassical manifestations that extend beyond the traditional syndromic descriptions. Multiple onconeural antibodies with high specificity for certain tumor types and neurological phenotypes have been discovered over the past 3 decades. Increasing use of immune checkpoint inhibitors (ICIs) has led to increased recognition of neurologic ICI-related adverse events. Some of these resemble PNS. In this article, we review the clinical, oncologic, and immunopathogenic associations of PNS.
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Affiliation(s)
- Jiraporn Jitprapaikulsan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pritikanta Paul
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois
| | - Smathorn Thakolwiboon
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Shivam Om Mittal
- Department of Neurology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota
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de Jonge H, Iamele L, Maggi M, Pessino G, Scotti C. Anti-Cancer Auto-Antibodies: Roles, Applications and Open Issues. Cancers (Basel) 2021; 13:813. [PMID: 33672007 PMCID: PMC7919283 DOI: 10.3390/cancers13040813] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 12/11/2022] Open
Abstract
Auto-antibodies are classically associated with autoimmune diseases, where they are an integral part of diagnostic panels. However, recent evidence is accumulating on the presence of auto-antibodies against single or selected panels of auto-antigens in many types of cancer. Auto-antibodies might initially represent an epiphenomenon derived from the inflammatory environment induced by the tumor. However, their effect on tumor evolution can be crucial, as is discussed in this paper. It has been demonstrated that some of these auto-antibodies can be used for early detection and cancer staging, as well as for monitoring of cancer regression during treatment and follow up. Interestingly, certain auto-antibodies were found to promote cancer progression and metastasis, while others contribute to the body's defense against it. Moreover, auto-antibodies are of a polyclonal nature, which means that often several antibodies are involved in the response to a single tumor antigen. Dissection of these antibody specificities is now possible, allowing their identification at the genetic, structural, and epitope levels. In this review, we report the evidence available on the presence of auto-antibodies in the main cancer types and discuss some of the open issues that still need to be addressed by the research community.
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Affiliation(s)
| | | | | | | | - Claudia Scotti
- Unit of Immunology and General Pathology, Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy; (H.d.J.); (L.I.); (M.M.); (G.P.)
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Devine MF, Kothapalli N, Elkhooly M, Dubey D. Paraneoplastic neurological syndromes: clinical presentations and management. Ther Adv Neurol Disord 2021; 14:1756286420985323. [PMID: 33796141 PMCID: PMC7970694 DOI: 10.1177/1756286420985323] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 12/11/2020] [Indexed: 12/17/2022] Open
Abstract
We provide an overview of the varied presentations of paraneoplastic neurological syndromes. We also review the onconeural antibodies and their particular oncological and neurological associations. Recognition of these syndromes and their oncological associations is crucial, as early diagnosis and management has been associated with better patient outcomes. Specific management strategies and prognosis vary widely depending on the underlying etiology. An understanding of the relevant clinical details, imaging findings, and other diagnostic information can help tailor treatment approaches. We provide an outline of the diagnostic evaluation and treatment of various paraneoplastic neurological disorders, presenting with central and/or peripheral nervous system involvement. We briefly discuss neurologic immune checkpoint inhibitor-related adverse events, which can occasionally present with paraneoplastic neurological syndrome phenotypes.
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Affiliation(s)
- Michelle F Devine
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Naga Kothapalli
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburg, PA, USA
| | | | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905-0002, USA
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Abstract
Associations between sleep disorders and neurological autoimmunity have been notably expanding recently. Potential immune-mediated etiopathogenesis has been proposed for various sleep disorders including narcolepsy, Kleine-Levin syndrome, and Morvan syndrome. Sleep manifestations are also common in various autoimmune neurological syndromes, but may be underestimated as overriding presenting (and potentially dangerous) neurological symptoms often require more urgent attention. Even so, sleep dysfunction has been described with various neural-specific antibody biomarkers, including IgLON5; leucine-rich, glioma-inactivated protein 1 (LGI1); contactin-associated protein 2 (CASPR2); N-methyl-D-aspartate (NMDA)-receptor; Ma2; dipeptidyl-peptidase-like protein-6 (DPPX); alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R); anti-neuronal nuclear antibody type-1 (ANNA-1, i.e., Hu); anti-neuronal nuclear antibody type-2 (ANNA-2, i.e., Ri); gamma-aminobutyric acid (GABA)-B-receptor (GABA-B-R); metabotropic glutamate receptor 5 (mGluR5); and aquaporin-4 (AQP-4). Given potentially distinctive findings, it is possible that sleep testing could potentially provide objective biomarkers (polysomnography, quantitative muscle activity during REM sleep, cerebrospinal fluid hypocretin-1) to support an autoimmune diagnosis, monitor therapeutic response, or disease progression/relapse. However, more comprehensive characterization of sleep manifestations is needed to better understand the underlying sleep disruption with neurological autoimmunity.
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Affiliation(s)
- Michelle F Devine
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA.
- Olmsted Medical Center, MN, Rochester, USA.
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Erik K St Louis
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Mayo Sleep Behavior and Neurophysiology Research Laboratory, Rochester, MN, USA
- Department of Medicine (Division of Pulmonary, Critical Care, and Sleep Medicine), Rochester, MN, USA
- Department of Neurology, Mayo Clinic Health System Southwest Wisconsin-La Crosse, Mayo Clinic and Foundation, Rochester, MN, USA
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Abstract
Hypothalamitis is a rare inflammatory disorder involving the hypothalamus and classified as primary, or isolated, and secondary hypothalamitis. Secondary hypothalamitis although very rare is more common than the primary one and may occur in patients affected by autoimmune diseases such as autoimmune hypophysitis, systemic autoimmune diseases, infective diseases in patients affected by immune-deficit, paraneoplastic encephalitis, or in patients treated with immune checkpoint inhibitors. In accordance with the rarity of this disease, diagnosis and management of hypothalamitis prove to be challenging. The diagnosis requires a high index of clinical suspicion. The main symptoms may be: various degrees of hypopituitarism, neuropsychiatric and behavioral disorders, and disturbances of autonomic and metabolic regulation. Magnetic resonance images play a crucial role in the diagnosis of hypothalamitis and in the exclusion of a neoplastic lesion. Therapeutic management should be oriented according to the disease etiology. In most cases, after ruling out infective hypothalamitis, the mainstay of therapy consists of immunosuppressive treatment. Great attention should be paid to hormonal replacement therapy, if partial or total hypopituitarism is present, in particular in patients affected by diabetes insipidus, central hypoadrenalism and hypothyroidism. According to the complexity of this disease, a multidisciplinary approach is strongly advocated to reach an early diagnosis and an integrated therapy.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Tartaglione
- Department of Radiology and Diagnostic Imaging, Istituto Dermatopatico dell'Immacolata IRCCS, Rome, Italy; Institute of Radiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Yshii L, Bost C, Liblau R. Immunological Bases of Paraneoplastic Cerebellar Degeneration and Therapeutic Implications. Front Immunol 2020; 11:991. [PMID: 32655545 PMCID: PMC7326021 DOI: 10.3389/fimmu.2020.00991] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic cerebellar degeneration (PCD) is a rare immune-mediated disease that develops mostly in the setting of neoplasia and offers a unique prospect to explore the interplay between tumor immunity and autoimmunity. In PCD, the deleterious adaptive immune response targets self-antigens aberrantly expressed by tumor cells, mostly gynecological cancers, and physiologically expressed by the Purkinje neurons of the cerebellum. Highly specific anti-neuronal antibodies in the serum and cerebrospinal fluid represent key diagnostic biomarkers of PCD. Some anti-neuronal antibodies such as anti-Yo autoantibodies (recognizing the CDR2/CDR2L proteins) are only associated with PCD. Other anti-neuronal antibodies, such as anti-Hu, anti-Ri, and anti-Ma2, are detected in patients with PCD or other types of paraneoplastic neurological manifestations. Importantly, these autoantibodies cannot transfer disease and evidence for a pathogenic role of autoreactive T cells is accumulating. However, the precise mechanisms responsible for disruption of self-tolerance to neuronal self-antigens in the cancer setting and the pathways involved in pathogenesis within the cerebellum remain to be fully deciphered. Although the occurrence of PCD is rare, the risk for such severe complication may increase with wider use of cancer immunotherapy, notably immune checkpoint blockade. Here, we review recent literature pertaining to the pathophysiology of PCD and propose an immune scheme underlying this disabling disease. Additionally, based on observations from patients' samples and on the pre-clinical model we recently developed, we discuss potential therapeutic strategies that could blunt this cerebellum-specific autoimmune disease.
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Affiliation(s)
- Lidia Yshii
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France
| | - Chloé Bost
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
| | - Roland Liblau
- INSERM U1043, CNRS UMR 5282, Université Toulouse III, Center for Pathophysiology Toulouse Purpan, Toulouse, France.,Department of Immunology, Purpan University Hospital Toulouse, Toulouse, France
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31
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Lee YH, Pang SW, Revai Lechtich E, Shah K, Simon SE, Ponnusamy S, Narayanan R, Poh CL, Tan KO. Tricistronic expression of MOAP-1, Bax and RASSF1A in cancer cells enhances chemo-sensitization that requires BH3L domain of MOAP-1. J Cancer Res Clin Oncol 2020; 146:1751-64. [DOI: 10.1007/s00432-020-03231-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 04/21/2020] [Indexed: 01/15/2023]
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32
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Affiliation(s)
- Adrian Budhram
- Departments of Clinical Neurological Sciences (Budhram, Nicolle, Burneo), and Medical Imaging (Leung), and the Neuroepidemiology Research Unit (Burneo), Western University, London, Ont.
| | - Andrew Leung
- Departments of Clinical Neurological Sciences (Budhram, Nicolle, Burneo), and Medical Imaging (Leung), and the Neuroepidemiology Research Unit (Burneo), Western University, London, Ont
| | - Michael W Nicolle
- Departments of Clinical Neurological Sciences (Budhram, Nicolle, Burneo), and Medical Imaging (Leung), and the Neuroepidemiology Research Unit (Burneo), Western University, London, Ont
| | - Jorge G Burneo
- Departments of Clinical Neurological Sciences (Budhram, Nicolle, Burneo), and Medical Imaging (Leung), and the Neuroepidemiology Research Unit (Burneo), Western University, London, Ont
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33
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Frerker B, Rohde M, Müller S, Bien CG, Köhling R, Kirschstein T. Distinct Effects of Stereotactically Injected Human Cerebrospinal Fluid Containing Glutamic Acid Decarboxylase Antibodies into the Hippocampus of Rats on the Development of Spontaneous Epileptic Activity. Brain Sci 2020; 10:brainsci10020123. [PMID: 32098388 PMCID: PMC7071523 DOI: 10.3390/brainsci10020123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Background: The conversion of glutamic acid into γ-aminobutyric acid (GABA) is catalyzed by the glutamic acid decarboxylase (GAD). Antibodies against this enzyme have been described in neurological disorders, but the pathophysiological role of these antibodies is still poorly understood. We hypothesized that anti-GAD autoantibodies could diminish the GABA content in the slice and facilitate epileptic activity. Methods: Cerebrospinal fluids (CSF) from two patients containing anti-GAD (A and B) were injected into the rat hippocampus in vivo. Hippocampal slices were prepared for electrophysiological field potential recordings in order to record recurrent epileptic discharges (REDs) in the CA1 region induced by the removal of Mg2+ and/or by adding gabazine. As control groups, we injected an anti-GAD-negative human CSF or saline solution, and we used non-operated naive animals. Results: RED frequencies were significantly higher in the Mg2+-free solution than in the gabazine-containing solution. The average frequency of REDs in the last 10 min and the average duration of REDs in the last 5 min did not show significant differences between the anti-GAD-B-treated and the control slices, but in the Mg2+-free solution, anti-GAD-A had significantly higher epileptic activity than anti-GAD-B. Conclusions: These results indicate that anti-GAD has distinct effects on the development of spontaneous epileptic activity.
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Affiliation(s)
- Bernd Frerker
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Department of Irradiation Therapy, University Hospital of Rostock, 18059 Rostock, Germany
- Correspondence: ; Tel.: +49(0)-381-494-9001; Fax: +49(0)-381-494-9002
| | - Marco Rohde
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
| | - Steffen Müller
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
| | | | - Rüdiger Köhling
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Center of Transdisciplinary Neurosciences Rostock, University of Rostock, 18147 Rostock, Germany
| | - Timo Kirschstein
- Oscar Langendorff Institute of Physiology, University of Rostock, 18057 Rostock, Germany
- Center of Transdisciplinary Neurosciences Rostock, University of Rostock, 18147 Rostock, Germany
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Peters J, Vijiaratnam N, Lo KY, Evans AH. Anti-Ma2-associated paraneoplastic encephalitis eat, sleep and repeat. Intern Med J 2020; 49:931-932. [PMID: 31295780 DOI: 10.1111/imj.14349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
- James Peters
- Department of Neurology, Western Health, Melbourne, Victoria, Australia
| | | | - Kar Yan Lo
- Department of Neurology, Western Health, Melbourne, Victoria, Australia
| | - Andrew H Evans
- Movement Disorder Service, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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35
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Vogrig A, Fouret M, Joubert B, Picard G, Rogemond V, Pinto AL, Muñiz-Castrillo S, Roger M, Raimbourg J, Dayen C, Grignou L, Pallix-Guyot M, Lannoy J, Ducray F, Desestret V, Psimaras D, Honnorat J. Increased frequency of anti-Ma2 encephalitis associated with immune checkpoint inhibitors. Neurol Neuroimmunol Neuroinflamm 2019; 6:6/6/e604. [PMID: 31454760 PMCID: PMC6705619 DOI: 10.1212/nxi.0000000000000604] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/08/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To report the induction of anti-Ma2 antibody-associated paraneoplastic neurologic syndrome (Ma2-PNS) in 6 patients after treatment with immune checkpoint inhibitors (ICIs). We also analyzed (1) patient clinical features compared with a cohort of 44 patients who developed Ma2-PNS without receiving ICI treatment and (2) the frequency of neuronal antibody detection before and after ICI implementation. METHODS Retrospective nationwide study of all patients with Ma2-PNS developed during ICI treatment between 2017 and 2018. RESULTS Our series of patients included 5 men and 1 woman (median age, 63 years). The patients were receiving nivolumab (n = 3), pembrolizumab (n = 2), or a combination of nivolumab and ipilimumab (n = 1) for treatment of neoplasms that included lung (n = 4) and kidney (n = 1) cancers and pleural mesothelioma (n = 1). Clinical syndromes comprised a combination of limbic encephalitis and diencephalitis (n = 3), isolated limbic encephalitis (n = 2), and a syndrome characterized by ophthalmoplegia and head drop (n = 1). No significant clinical difference was observed between our 6 patients and the overall cohort of Ma2-PNS cases. Post-ICI Ma2-PNS accounted for 35% of the total 17 Ma2-PNS diagnosed in our center over the 2017-2018 biennium. Eight cases had been detected in the preceding biennium 2015-2016, corresponding to a 112% increase of Ma2-PNS frequency since the implementation of ICIs in France. Despite ICI withdrawal and immunotherapy, 4/6 patients died, and the remaining 2 showed a moderate to severe disability. CONCLUSIONS We show a clear association between ICI use and increased diagnosis of Ma2-PNS. Physicians need to be aware that ICIs can trigger Ma2-PNS because clinical presentation can be challenging.
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Affiliation(s)
- Alberto Vogrig
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marine Fouret
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Bastien Joubert
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Géraldine Picard
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Véronique Rogemond
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Anne-Laurie Pinto
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Sergio Muñiz-Castrillo
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Maxime Roger
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Judith Raimbourg
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Charles Dayen
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Laurianne Grignou
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Maud Pallix-Guyot
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Julien Lannoy
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - François Ducray
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Virginie Desestret
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Dimitri Psimaras
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jérôme Honnorat
- From the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (A.V., M.F., B.J., G.P., V.R., A.-L.P., S.M.-C., F.D., V.D., J.H.), Hospices Civils de Lyon, Hôpital Neurologique; Synatac Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France; University Claude Bernard Lyon 1, Université de Lyon; Service de Pneumologie-Oncologie Thoracique-Soins Intensifs Respiratoires (M.R.), Centre Hospitalier Universitaire de Rouen; Service d'Oncologie Médicale (J.R.), Institut de Cancérologie de l'Ouest René Gauducheau, St. Herblain; Service de Pneumologie (C.D.), Centre Hospitalier de Saint-Quentin; Service de Neurologie et Unité Neuro-Vasculaire-Hôpital de La Cavale Blanche (L.G.), Brest; Service de Neurologie et Unité Neurovasculaire (M.P.-G.), Centre Hospitalier Régional d'Orléans; Service de Neurologie-Pathologies Inflammatoires (J.L.), Centre Hospitalier Universitaire de Lille; and AP-HP (D.P.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975; Inserm U 975, CNRS, UMR 7225; Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Mandel-Brehm C, Dubey D, Kryzer TJ, O'Donovan BD, Tran B, Vazquez SE, Sample HA, Zorn KC, Khan LM, Bledsoe IO, McKeon A, Pleasure SJ, Lennon VA, DeRisi JL, Wilson MR, Pittock SJ. Kelch-like Protein 11 Antibodies in Seminoma-Associated Paraneoplastic Encephalitis. N Engl J Med 2019; 381:47-54. [PMID: 31269365 PMCID: PMC6800027 DOI: 10.1056/nejmoa1816721] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 37-year-old man with a history of seminoma presented with vertigo, ataxia, and diplopia. An autoantibody specific for kelch-like protein 11 (KLHL11) was identified with the use of programmable phage display. Immunoassays were used to identify KLHL11 IgG in 12 other men with similar neurologic features and testicular disease. Immunostaining of the patient's IgG on mouse brain tissue showed sparse but distinctive points of staining in multiple brain regions, with enrichment in perivascular and perimeningeal tissues. The onset of the neurologic syndrome preceded the diagnosis of seminoma in 9 of the 13 patients. An age-adjusted estimate of the prevalence of autoimmune KLHL11 encephalitis in Olmsted County, Minnesota, was 2.79 cases per 100,000 men. (Funded by the Rochester Epidemiology Project and others.).
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Affiliation(s)
- Caleigh Mandel-Brehm
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Thomas J Kryzer
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Brian D O'Donovan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Baouyen Tran
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sara E Vazquez
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Hannah A Sample
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Kelsey C Zorn
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Lillian M Khan
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Ian O Bledsoe
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Samuel J Pleasure
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Joseph L DeRisi
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Michael R Wilson
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Department of Biochemistry and Biophysics (C.M.-B., B.D.O., S.E.V., H.A.S., K.C.Z., L.M.K., J.L.D.), the Weill Institute for Neurosciences (B.T., I.O.B., S.J. Pleasure, M.R.W.), the Department of Neurology (B.T., I.O.B., S.J. Pleasure, M.R.W.), and the Chan Zuckerberg Biohub (J.L.D.), University of California, San Francisco, San Francisco; and the Departments of Laboratory Medicine and Pathology (D.D., T.J.K., A.M., V.A.L., S.J. Pittock), Neurology (D.D., A.M., V.A.L., S.J. Pittock), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN
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Abstract
The field of autoimmune epilepsy has evolved substantially in the last few decades with discovery of several neural autoantibodies and improved mechanistic understanding of these immune-mediated syndromes. A considerable proportion of patients with epilepsy of unknown etiology have been demonstrated to have an autoimmune cause. The majority of the patients with autoimmune epilepsy usually present with new-onset refractory seizures along with subacute progressive cognitive decline and behavioral or psychiatric dysfunction. Neural specific antibodies commonly associated with autoimmune epilepsy include leucine-rich glioma-inactivated protein 1 (LGI1), N-methyl-D-aspartate receptor (NMDA-R), and glutamic acid decarboxylase 65 (GAD65) IgG. Diagnosis of these cases depends on the identification of the clinical syndrome and ancillary studies including autoantibody evaluation. Predictive models (Antibody Prevalence in Epilepsy and Encephalopathy [APE2] and Response to Immunotherapy in Epilepsy and Encephalopathy [RITE2] scores) based on clinical features and initial neurological assessment may be utilized for selection of cases for autoimmune epilepsy evaluation and management. In this article, we will review the recent advances in autoimmune epilepsy and provide diagnostic and therapeutic algorithms for epilepsies with suspected autoimmune etiology.
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Affiliation(s)
- Khalil S Husari
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Divyanshu Dubey
- Department of Neurology and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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Fominykh VV, Frei EA, Brylev LV, Gulyaeva NV. Autoimmune Encephalitis: A Disease of the 21st Century at the Crossroads of Neurology and Psychiatry. NEUROCHEM J+ 2018. [DOI: 10.1134/s1819712418040037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Takewaki D, Lin Y, Sato W, Ono H, Nakamura M, Araki M, Okamoto T, Takahashi Y, Kimura Y, Ota M, Sato N, Yamamura T. Normal brain imaging accompanies neuroimmunologically justified, autoimmune encephalomyelitis. Neurol Neuroimmunol Neuroinflamm 2018; 5:e456. [PMID: 29616233 PMCID: PMC5880628 DOI: 10.1212/nxi.0000000000000456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/27/2018] [Indexed: 12/30/2022]
Abstract
Objective To examine cases with a clinical course, signs, and symptoms mimicking MS, but without abnormalities on conventional MRI. Methods Among 550 people with a tentative diagnosis of MS or neuromyelitis optica spectrum disorder (NMOSD), we selected patients, who met the 2010 McDonald diagnosis criteria for MS, but did not show abnormal findings on conventional brain and spinal cord MRI. After evaluating their clinical data, we analyzed fractional anisotropy (FA) values in the brain white matter on diffusion tensor MRIs and the frequencies of B-cell subsets in the peripheral blood in the corresponding cases as compared to healthy controls. Results Eleven patients (age: 41.1 ± 8.0 years, 9 women and 2 men) met the selection criteria. They were functionally disabled, with a median expanded disability status scale score of 6.0 (2.0–8.0). CSF oligoclonal bands were negative in all cases. IV methylprednisolone and plasmapheresis (PP) were found to be efficacious. Diffusion tensor MRI analysis revealed extensive white matter abnormalities characterized by significantly decreased FA values. The frequency of plasmablasts in the peripheral blood was significantly increased in these patients similar to NMOSD. Conclusions The neurologic disabilities in these patients could be ascribed to brain white matter damage, as revealed by MRI analysis, whereas the efficacy of PP and B-cell abnormalities in the patients suggested an autoimmune-mediated pathogenesis. In the differential diagnosis of MS, we propose that this condition be referred to as, “Normal-appearing Imaging-associated, Neuroimmunologically Justified, Autoimmune encephalomyelitis.”
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Affiliation(s)
- Daiki Takewaki
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Youwei Lin
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Wakiro Sato
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hirohiko Ono
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masakazu Nakamura
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Manabu Araki
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Tomoko Okamoto
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuji Takahashi
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yukio Kimura
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Miho Ota
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Noriko Sato
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takashi Yamamura
- Department of Immunology (D.T., Y.L., W.S., H.O., M.N., M.A., T.Y.) and Department of Mental Disorder Research (M.O.), National Institute of Neuroscience, National Center of Neurology and Psychiatry; Department of Neurology (D.T., Y.L., M.A., T.O., Y.T.) and Department of Radiology (Y.K., N.S.), National Center Hospital, National Center of Neurology and Psychiatry; Multiple Sclerosis Center (D.T., Y.L., W.S., H.O., M.N., M.A., T.O., N.S., T.Y.), National Center of Neurology and Psychiatry, Tokyo, Japan
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Siles AM, Martínez‐Hernández E, Araque J, Diaz‐Manera J, Rojas‐Garcia R, Gallardo E, Illa I, Graus F, Querol L. Antibodies against cell adhesion molecules and neural structures in paraneoplastic neuropathies. Ann Clin Transl Neurol 2018; 5:559-569. [PMID: 29761119 PMCID: PMC5945957 DOI: 10.1002/acn3.554] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 12/16/2022] Open
Abstract
Objective Paraneoplastic neurological syndromes (PNS) are rare neurological disorders in which ectopic expression of neural antigens by a tumor results in an autoimmune attack against the nervous system. Onconeural antibodies not only guide PNS diagnosis but may also help detecting underlying malignancies. Our project aims to uncover new potential antibodies in paraneoplastic neuropathies (PN). Methods Thirty‐four patients fulfilling diagnostic criteria of possible (n = 9; 26.5%) and definite (n = 25; 73.5%) PN without onconeural antibodies and 28 healthy controls were included in our study. Sera were tested for known antibodies against neural cell adhesion molecules and screened for novel IgG and IgM reactivities against nerve components: dorsal root ganglia (DRG) neurons, motor neurons, and Schwann cells. Patients showing autoantibodies against any of these cell types were used for immunoprecipitation (IP) studies. Results Overall, 9 (26.5%) patients showed significant reactivity against DRG neurons, motor neurons, or Schwann cells, whereas 5 (17.9%) healthy controls only showed moderate reactivity. Compared with control sera, serum samples from patients with paraneoplastic sensory‐motor neuropathies had a higher frequency of IgM antibodies against Schwann cells (0% vs. 40%; P = 0.0028). No novel antigens were identified from our IP experiments. Antibodies against the neural adhesion molecules CNTN1, NF155, NF140, NF186, NCAM1, L1CAM, and the CNTN1/CASPR1 complex were not detected in patients with PN. One (2.9%) patient with CIDP and thymoma had CASPR2 antibodies. Interpretation Almost 30% of patients with PN harbor antibodies targeting neural structures, suggesting that novel neoplasm‐associated antigens remain to be discovered.
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Affiliation(s)
- Ana M. Siles
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Eugenia Martínez‐Hernández
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
- Service of Neurology and NeuroimmunologyAugust Pi Sunyer Biomedical Research Institute (IDIBAPS)Hospital ClínicUniversity of BarcelonaSpain
| | - Josefa Araque
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Jordi Diaz‐Manera
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Ricard Rojas‐Garcia
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Eduard Gallardo
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Isabel Illa
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
| | - Francesc Graus
- Service of Neurology and NeuroimmunologyAugust Pi Sunyer Biomedical Research Institute (IDIBAPS)Hospital ClínicUniversity of BarcelonaSpain
| | - Luis Querol
- Neuromuscular Diseases UnitNeurology DepartmentHospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER)MadridSpain
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Pang SW, Lahiri C, Poh CL, Tan KO. PNMA family: Protein interaction network and cell signalling pathways implicated in cancer and apoptosis. Cell Signal 2018; 45:54-62. [PMID: 29378289 DOI: 10.1016/j.cellsig.2018.01.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/23/2018] [Accepted: 01/23/2018] [Indexed: 12/22/2022]
Abstract
Paraneoplastic Ma Family (PNMA) comprises a growing number of family members which share relatively conserved protein sequences encoded by the human genome and is localized to several human chromosomes, including the X-chromosome. Based on sequence analysis, PNMA family members share sequence homology to the Gag protein of LTR retrotransposon, and several family members with aberrant protein expressions have been reported to be closely associated with the human Paraneoplastic Disorder (PND). In addition, gene mutations of specific members of PNMA family are known to be associated with human mental retardation or 3-M syndrome consisting of restrictive post-natal growth or dwarfism, and development of skeletal abnormalities. Other than sequence homology, the physiological function of many members in this family remains unclear. However, several members of this family have been characterized, including cell signalling events mediated by these proteins that are associated with apoptosis, and cancer in different cell types. Furthermore, while certain PNMA family members show restricted gene expression in the human brain and testis, other PNMA family members exhibit broader gene expression or preferential and selective protein interaction profiles, suggesting functional divergence within the family. Functional analysis of some members of this family have identified protein domains that are required for subcellular localization, protein-protein interactions, and cell signalling events which are the focus of this review paper.
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Affiliation(s)
- Siew Wai Pang
- Department of Biological Sciences, Sunway University, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia
| | - Chandrajit Lahiri
- Department of Biological Sciences, Sunway University, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia
| | - Chit Laa Poh
- Research Centre for Biomedical Sciences, Sunway University, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia
| | - Kuan Onn Tan
- Department of Biological Sciences, Sunway University, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia.
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Freifeld Y, Kapur P, Chitkara R, Lee F, Khemani P, Bagrodia A. Metastatic "Burned Out" Seminoma Causing Neurological Paraneoplastic Syndrome-Not Quite "Burned Out". Front Neurol 2018; 9:20. [PMID: 29441039 PMCID: PMC5797537 DOI: 10.3389/fneur.2018.00020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022] Open
Abstract
A 44-year-old man presented with cerebellar ataxia and limbic encephalitis and was ultimately diagnosed with metastatic germ cell neoplasm resulting from a "burned out" primary testicular tumor. The patient had progressive ataxia, leading to a thorough investigation for infectious, autoimmune, metabolic, and malignant causes of acquired cerebellar ataxia that revealed no significant findings. Testicular sonography demonstrated a possible right testicular lesion that was not confirmed on radical inguinal orchiectomy. F18-FDG positron emission tomography/computerized tomography scan revealed a solitary retroperitoneal lesion, concerning for metastatic disease but not amenable to percutaneous biopsy. A robotic retroperitoneal lymph node dissection was performed and pathology revealed a CD117-positive metastatic seminoma leading to appropriate germ cell tumor-directed chemotherapy. After completing chemotherapy and during 1 year of follow-up, there has been a gradual improvement of the patient's neurological manifestations.
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Affiliation(s)
- Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Payal Kapur
- Department of Pathology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Ritika Chitkara
- Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Francesca Lee
- Division of Infectious Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Pravin Khemani
- Department of Neurology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
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Bustos M, Berger H, Hannoush ZC, Ayala A, Freire R, Kargi AY. Anti-Ma-1 and Anti-Ma-2 Antibodies in Isolated Fatal Hypothalamitis. J Endocr Soc 2018; 2:106-111. [PMID: 29379898 PMCID: PMC5783447 DOI: 10.1210/js.2017-00354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/28/2017] [Indexed: 11/19/2022] Open
Abstract
Lymphocytic hypothalamitis (LHT) is a rare disease characterized by pituitary dysfunction, autonomic instability, metabolic disturbances, and neuropsychiatric disorders. We report the case of a 30-year-old man found to have LHT that progressed despite treatment with methylprednisolone and intravenous immunoglobulin (IVIG). A literature review was conducted to identify prior studies pertaining to LHT. Our patient presented with several weeks of fatigue, cold intolerance, weight loss, confusion, and headache. Laboratory tests were consistent with panhypopituitarism. Brain magnetic resonance imaging revealed an infiltrative enhancing mass in the area of the hypothalamus, and stereotactic biopsy findings showed reactive inflammatory changes. A course of hormone replacement (levothyroxine), methylprednisolone, and IVIG was initiated. The patient’s course was complicated by a fatal tonsillar herniation. Autopsy revealed LHT. The diagnosis and management of autoimmune LHT are challenging. The entity should be considered in the setting of panhypopituitarism with a hypothalamic mass. Differentiating paraneoplastic and nonparaneoplastic hypothalamitis should be established for management and prognosis. Definitive treatment remains unclear; treatment with corticosteroids should be attempted, followed by consideration of other immunosuppressive agents, such as rituximab. If a paraneoplastic syndrome is suspected, management should also be directed toward the primary tumor.
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Affiliation(s)
- Mario Bustos
- University of Miami Miller School of Medicine at Holy Cross Hospital, Fort Lauderdale, Florida 33308
| | - Hara Berger
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Zeina Carolina Hannoush
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Alejandro Ayala
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Rochelle Freire
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida 33136
| | - Atil Yilmaz Kargi
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136
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Abstract
SummaryAutoimmune encephalitides can present with altered mental states, particularly psychosis and delirium. Psychiatrists need to be particularly vigilant in cases of first-episode psychosis and to look out for other, sometimes subtle, features of encephalitis. Encephalitis related to N-methyl-d-aspartate (NMDA) receptor autoantibodies is the most common autoimmune cause of isolated psychosis, the second being related to voltage-gated potassium channel (VGKC)-complex antibodies. Psychiatrists should note ‘red flag’ signs of seizures, autonomic instability, movement disorders and sensitivity to antipsychotic medication (including neuroleptic malignant syndrome). They should also be aware that, in some cases, encephalitis is a non-metastatic manifestation of malignancy. Treatment primarily involves suppression of immunity and is often successful if delivered early. There is accumulating evidence that isolated psychiatric syndromes can be caused by autoimmunity and this could potentially signal a significant change in the approach to disorders such as schizophrenia. Psychiatrists and neurologists need to work together to diagnose, manage and understand this group of conditions.LEARNING OBJECTIVES•Consider ‘red flags' for the diagnosis of autoimmune encephalitis presenting to general psychiatric practice.•Understand the investigations required to diagnose autoimmune encephalitis.•Become familiar with the basics of treatment of autoimmune encephalitis.
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Ortega Suero G, Sola-valls N, Escudero D, Saiz A, Graus F. Anti-Ma and anti-Ma2-associated paraneoplastic neurological syndromes. Neurología (English Edition) 2018; 33:18-27. [DOI: 10.1016/j.nrleng.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Abstract
Paraneoplastic and autoimmune encephalitis comprise a group of immune-mediated disorders that are associated with different immune effector mechanisms. Classic paraneoplastic neurologic syndromes are triggered by an antitumor immune response. The disease is considered to result from a T-cell response; in addition, patients harbour high titers of autoantibodies against intracellular antigens that are considered as epiphenomenon but are useful diagnostic markers. Neuropathology consists of T-cell-dominated inflammation, marked neuronal loss, and microglial activation with upregulation of HLA-DR. In the last decade, an increasing number of diseases associated with autoantibodies against neuronal surface antigens have been described. There is strong evidence that these autoantibodies are pathogenic and the associated syndromes are generally termed as antineuronal autoimmune encephalitis. Patients typically present with limbic, multifocal, or diffuse encephalitis and respond to immunotherapy. Neuropathologic descriptions are restricted to few biopsy and autopsy specimens and show mild inflammatory infiltrates and microglial activation, together with reduced expression of the respective target antigens, immunoglobulin deposits, and a variable degree of complement activation. Other putative autoimmune disorders of the central nervous system include, among others, Rasmussen encephalitis, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), acute cerebellitis, Susac syndrome, and Hashimoto encephalitis. While pathologic studies suggest an immune-mediated disease for Rasmussen encephalitis, CLIPPERS, acute cerebellitis, and Susac syndrome, neuropathologic descriptions of Hashimoto encephalitis are rare and the pathogenesis deserves further study.
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Affiliation(s)
- Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Vienna, Austria.
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Ju W, Qi B, Wang X, Yang Y. Anti-Ma2-associated limbic encephalitis with coexisting chronic inflammatory demyelinating polyneuropathy in a patient with non-Hodgkin lymphoma: A case report. Medicine (Baltimore) 2017; 96:e8228. [PMID: 28984777 PMCID: PMC5738013 DOI: 10.1097/md.0000000000008228] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE We report the rare case of a 74-year-old man with anti-Ma2-associated paraneoplastic neurologic syndrome (PNS), and review and analyze the clinical manifestations, diagnosis, and treatment of the disease. PATIENT CONCERNS The patient presented with a 5-month history of muscle weakness, progressive body aches, and weakness and numbness in both lower extremities. Before his hospitalization, he had experienced cognitive function decline; ptosis, inward gaze, and vertical gaze palsy in the right eye; and occasional visual hallucinations. Brain and spinal cord magnetic resonance imaging (MRI) yielded normal results. Anti-Ma2 antibodies were detected in both serum and cerebrospinal fluid. A 4-hour electroencephalogram showed irregular sharp slow waves and δ waves in the temporal region. Electromyography showed peripheral nerve demyelination. Positron-emission tomography/computed tomography (PET-CT) examination revealed hypermetabolism in the lymph nodes of the whole body. Biopsy of the lymph nodes showed non-Hodgkin lymphoma. DIAGNOSIS A clinical diagnosis of lymphoma and PNS was made. INTERVENTIONS The patient was treated with intravenous dexamethasone (15 mg/day) for 3 days. LESSONS We have presented a rare case of a PNS involving both the central and peripheral nervous systems. The clinical features of this case indicated anti-Ma2-associated encephalitis and chronic inflammatory demyelinating polyneuropathy. PET-CT played a critical role in enabling early diagnosis and prompt treatment in this case.
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Affiliation(s)
| | - Baochang Qi
- Department of Orthopedic Trauma, the First Hospital of Jilin University, Changchun, Jilin, China
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