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Gadian J, Eyre M, Konstantoulaki E, Almoyan A, Absoud M, Garrood I, Lim M. Neurological and cognitive outcomes after antibody-negative autoimmune encephalitis in children. Dev Med Child Neurol 2022; 64:649-653. [PMID: 34724211 DOI: 10.1111/dmcn.15101] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/16/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022]
Abstract
AIM To characterize the neurological and cognitive outcomes in children with antibody-negative autoimmune encephalitis (Ab-negative AE). METHOD A cohort of children presenting to our institution over a 10-year period with autoimmune encephalitis was identified by structured retrospective review of medical records. Clinical features at presentation and final follow-up were recorded. Neuropsychological testing was performed in a subset of patients. Outcomes after Ab-negative AE were compared with outcomes after N-methyl-D-aspartate receptor antibody encephalitis (NMDARE). RESULTS Forty-four patients (26 females, 18 males, median age 9y 2mo [interquartile range 4y 5mo-11y 8mo], 23 with NMDARE) with a diagnosis of autoimmune encephalitis were included. Postencephalitic epilepsy was more frequent after Ab-negative AE compared to NMDARE (61% vs 14%, p=0.002). Cognitive testing was performed in a subset of patients (n=21; Ab-negative AE=11, NMDARE=10). Full-scale IQ was lower after Ab-negative AE than NMDARE (mean IQ 75 vs 92, p=0.02), primarily because of reduced verbal comprehension index (80 vs 98, p=0.01) and working memory index (77 vs 95, p=0.09). The cognitive function most commonly impaired was executive function (80% [8/10] vs 22% [2/9]). INTERPRETATION Ab-negative AE was associated with poorer cognitive outcomes than NMDARE at 1-year follow-up. Further studies are required to evaluate if immunotherapy can be optimized to improve outcome.
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Affiliation(s)
- Jonathan Gadian
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Eyre
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK.,School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Ele Konstantoulaki
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK
| | - Ani Almoyan
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Absoud
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK.,Department Women and Children's Health, School of Life Course Sciences (SoLCS), King's College London, London, UK
| | - Isabel Garrood
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK
| | - Ming Lim
- Evelina London Children's Hospital, Children's Neurosciences Centre, London, UK.,Department Women and Children's Health, School of Life Course Sciences (SoLCS), King's College London, London, UK
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Tan NB, Pagnamenta AT, Ferla MP, Gadian J, Chung BH, Chan MC, Fung JL, Cook E, Guter S, Boschann F, Heinen A, Schallner J, Mignot C, Keren B, Whalen S, Sarret C, Mittag D, Demmer L, Stapleton R, Saida K, Matsumoto N, Miyake N, Sheffer R, Mor-Shaked H, Barnett CP, Byrne AB, Scott HS, Kraus A, Cappuccio G, Brunetti-Pierri N, Iorio R, Di Dato F, Pais LS, Yeung A, Tan TY, Taylor JC, Christodoulou J, White SM. Recurrent de novo missense variants in GNB2 can cause syndromic intellectual disability. J Med Genet 2021; 59:511-516. [PMID: 34183358 DOI: 10.1136/jmedgenet-2020-107462] [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: 09/17/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Binding proteins (G-proteins) mediate signalling pathways involved in diverse cellular functions and comprise Gα and Gβγ units. Human diseases have been reported for all five Gβ proteins. A de novo missense variant in GNB2 was recently reported in one individual with developmental delay/intellectual disability (DD/ID) and dysmorphism. We aim to confirm GNB2 as a neurodevelopmental disease gene, and elucidate the GNB2-associated neurodevelopmental phenotype in a patient cohort. METHODS We discovered a GNB2 variant in the index case via exome sequencing and sought individuals with GNB2 variants via international data-sharing initiatives. In silico modelling of the variants was assessed, along with multiple lines of evidence in keeping with American College of Medical Genetics and Genomics guidelines for interpretation of sequence variants. RESULTS We identified 12 unrelated individuals with five de novo missense variants in GNB2, four of which are recurrent: p.(Ala73Thr), p.(Gly77Arg), p.(Lys89Glu) and p.(Lys89Thr). All individuals have DD/ID with variable dysmorphism and extraneurologic features. The variants are located at the universally conserved shared interface with the Gα subunit, which modelling suggests weaken this interaction. CONCLUSION Missense variants in GNB2 cause a congenital neurodevelopmental disorder with variable syndromic features, broadening the spectrum of multisystem phenotypes associated with variants in genes encoding G-proteins.
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Affiliation(s)
- Natalie B Tan
- Victorian Clinical Genetics Services, Parkville, Victoria 3052, Australia.,Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.,Department of Paediatrics, The University of Melbourne, Parkville 3052, Victoria, Australia
| | - Alistair T Pagnamenta
- NIHR Oxford BRC, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Matteo P Ferla
- NIHR Oxford BRC, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Jonathan Gadian
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Brian Hy Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Marcus Cy Chan
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Jasmine Lf Fung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Edwin Cook
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois at Chicago, Chicago 60608, Illinois, USA
| | - Stephen Guter
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois at Chicago, Chicago 60608, Illinois, USA
| | - Felix Boschann
- Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany
| | - Andre Heinen
- Carl Gustav Carus Faculty of Medicine, Children's Hospital, Technical University Dresden, Dresden, Germany
| | - Jens Schallner
- Department of Neuropediatrics, Carl Gustav Carus Faculty of Medicine, Children's Hospital, Technical University Dresden, Dresden, Germany
| | - Cyril Mignot
- Département de Génétique, Hôpital Pitié-Salpêtrière, APHP.Sorbonne Université, Paris, France
| | - Boris Keren
- Département de Génétique, Hôpital Pitié-Salpêtrière, APHP.Sorbonne Université, Paris, France
| | - Sandra Whalen
- UF de Génétique Clinique, Centre de Référence Maladies Rares Anomalies du développement et syndromes malformatifs, APHP.Sorbonne Université, Hôpital Armand Trousseau, Paris, France
| | - Catherine Sarret
- Service de génétique médicale, Hôpital Estaing, Centre hospitalo-universitaire de Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Dana Mittag
- Division of Genetics, Levine Children's Hospital, Carolinas Medical Center, Atrium Health, Charlotte 28232-2861, North Carolina, USA
| | - Laurie Demmer
- Division of Genetics, Levine Children's Hospital, Carolinas Medical Center, Atrium Health, Charlotte 28232-2861, North Carolina, USA
| | - Rachel Stapleton
- Genetic Health Service NZ, Christchurch Hospital, Christchurch 8140, New Zealand
| | - Ken Saida
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Noriko Miyake
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Ruth Sheffer
- Department of Human Genetics, Hadassah University Hospital, Jerusalem, Israel
| | - Hagar Mor-Shaked
- Department of Human Genetics, Hadassah University Hospital, Jerusalem, Israel
| | - Christopher P Barnett
- South Australian Clinical Genetics Service, Women's and Children's Hospital, North Adelaide 5006, South Australia, Australia
| | - Alicia B Byrne
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, Adelaide, South Australia, Australia.,UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Hamish S Scott
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, Adelaide, South Australia, Australia
| | - Alison Kraus
- Yorkshire Regional Genetics Service, Chapel Allerton Hospital, Leeds 0113 392 4455, UK.,Castle Hill Hospital, Cottingham, Hull 01482 622470, UK
| | - Gerarda Cappuccio
- Department of Translational Medicine, Section of Pediatrics, Federico II University Hospital, Naples, Italy.,Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
| | - Nicola Brunetti-Pierri
- Department of Translational Medicine, Section of Pediatrics, Federico II University Hospital, Naples, Italy.,Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medicine, Section of Pediatrics, Federico II University Hospital, Naples, Italy
| | - Fabiola Di Dato
- Department of Translational Medicine, Section of Pediatrics, Federico II University Hospital, Naples, Italy
| | - Lynn S Pais
- Center for Mendelian Genomics, Eli and Edythe L Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
| | - Alison Yeung
- Victorian Clinical Genetics Services, Parkville, Victoria 3052, Australia.,Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.,Department of Paediatrics, The University of Melbourne, Parkville 3052, Victoria, Australia
| | - Tiong Y Tan
- Victorian Clinical Genetics Services, Parkville, Victoria 3052, Australia.,Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.,Department of Paediatrics, The University of Melbourne, Parkville 3052, Victoria, Australia
| | - Jenny C Taylor
- NIHR Oxford BRC, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - John Christodoulou
- Victorian Clinical Genetics Services, Parkville, Victoria 3052, Australia .,Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.,Department of Paediatrics, The University of Melbourne, Parkville 3052, Victoria, Australia
| | - Susan M White
- Victorian Clinical Genetics Services, Parkville, Victoria 3052, Australia .,Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.,Department of Paediatrics, The University of Melbourne, Parkville 3052, Victoria, Australia
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Eyre M, Hacohen Y, Lamb K, Absoud M, Agrawal S, Gadian J, Gupta R, Kneen R, Milford DV, Philip S, Rose K, Smith M, Spinty S, Wassmer E, Lim M, Hemingway C. Utility and safety of plasma exchange in paediatric neuroimmune disorders. Dev Med Child Neurol 2019; 61:540-546. [PMID: 30659589 DOI: 10.1111/dmcn.14150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2018] [Indexed: 12/27/2022]
Abstract
AIM Our aim was to ascertain the indications, side effects, and outcomes in children receiving therapeutic plasma exchange (TPE) for neurological disorders. METHOD Medical records were retrospectively reviewed for 58 consecutive children (age ≤16y) undergoing 67 courses of TPE across four tertiary centres. Patient characteristics, treatment schedules, complications, and outcomes were analysed. RESULTS Median age at initiation of TPE was 9 years (range 1-15y). Indications included peripheral nervous system (PNS; n=18) and central nervous system (CNS; n=40) disorders. Courses comprised a median six exchanges (range 2-179) over 8 days (range 3-466). Forty-two out of 58 (73%) children were severely disabled (bedridden) at initiation and 24 out of 58 (41%) were admitted to intensive care units. Treating clinicians' impression of response was positive in 16 out of 18 of those with PNS disorders versus 22 out of 40 with CNS disorders (p=0.016). Improvements in disability (modified Rankin Scale) occurred in 13 out of 58 (22%) children by completion of TPE (p=0.003). Complications occurred in 40 out of 67 (60%) courses, of which 16 out of 67 (24%) were line related. Potentially life-threatening complications occurred in 2 out of 67 (3%) courses. INTERPRETATION This cohort study provides safety and efficacy information for clinicians and families and a basis for future prospective studies. WHAT THIS PAPER ADDS Disability scores for severe neuroimmune disorders remained stable or improved during therapeutic plasma exchange treatment. Complications occurred frequently but were typically mild and correctable.
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Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Kate Lamb
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Michael Absoud
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shakti Agrawal
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jonathan Gadian
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Rajat Gupta
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Rachel Kneen
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - David V Milford
- Department of Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Sunny Philip
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Katie Rose
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Martin Smith
- Department of Paediatric Neurology, Oxford Children's Hospital, Oxford, UK
| | - Stefan Spinty
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
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Nosadini M, Gadian J, Lim M, Sartori S, Thomas T, Dale RC. Mycophenolate mofetil in paediatric autoimmune or immune-mediated diseases of the central nervous system: clinical experience and recommendations. Dev Med Child Neurol 2019; 61:458-468. [PMID: 30221751 DOI: 10.1111/dmcn.14020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 12/14/2022]
Abstract
AIM To gather data on mycophenolate mofetil (MMF) in paediatric autoimmune/immune-mediated central nervous system (CNS) conditions, focusing on safety and factors that may affect MMF efficacy. METHOD Retrospective, multicentre study based on four paediatric neurology centres. RESULTS Forty-four children were included (30 females, 14 males): 19 had proven/suspected autoimmune encephalitis, 14 had inflammatory demyelinating CNS diseases, and 11 had other autoimmune/immune-mediated CNS conditions. Before MMF, all received first-line immune therapies, and 17 had second-line rituximab and/or cyclophosphamide. MMF was started at a median of 9.5 months from disease onset (range 1-127mo) (median age 9y 4mo, range 1y 5mo-16y 5mo), and was used for median 18 months (range 0.3-73mo). On MMF, 31 patients were relapse-free, whereas eight relapsed (excluding patients with chronic-progressive course). Relapses on MMF were associated with medication weaning/cessation, or with suboptimal MMF dosage/duration. Adverse events of MMF occurred in eight patients: six moderate (gastrointestinal, movement disorder, dermatological) and two severe (infectious). INTERPRETATION MMF use in paediatric neuroimmunology is heterogeneous, although relatively safe. We have identified factors that may affect MMF efficacy and provide recommendations on MMF usage. WHAT THIS PAPER ADDS Mycophenolate mofetil (MMF) use was heterogeneous with relatively common adverse events, although mostly not severe. MMF treatment reduced median annualized relapse rate, although 20% of patients relapsed on MMF. A high relapse rate pre-MMF and late MMF start were associated with higher probability of relapsing on MMF. Most relapses were associated with suboptimal MMF dosage, short MMF duration, or concurrent medication weaning/discontinuation.
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Affiliation(s)
- Margherita Nosadini
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research at the Children's Hospital at Westmead, University of Sydney, Westmead, Australia.,Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Jonathan Gadian
- Children's Neurosciences Centre, Guy's & St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, Evelina London Children's Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ming Lim
- Children's Neurosciences Centre, Guy's & St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, Evelina London Children's Hospital, London, UK
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research at the Children's Hospital at Westmead, University of Sydney, Westmead, Australia
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Gadian J, Kirk E, Holliday K, Lim M, Absoud M. Systematic review of immunoglobulin use in paediatric neurological and neurodevelopmental disorders. Dev Med Child Neurol 2017; 59:136-144. [PMID: 27900773 DOI: 10.1111/dmcn.13349] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 01/18/2023]
Abstract
AIM A systematic literature review of intravenous immunoglobulin (IVIG) treatment of paediatric neurological conditions was performed to summarize the evidence, provide recommendations, and suggest future research. METHOD A MEDLINE search for articles reporting on IVIG treatment of paediatric neuroinflammatory, neurodevelopmental, and neurodegenerative conditions published before September 2015, excluding single case reports and those not in English. Owing to heterogeneous outcome measures, meta-analysis was not possible. Findings were combined and evidence graded. RESULTS Sixty-five studies were analysed. IVIG reduces recovery time in Guillain-Barré syndrome (grade B). IVIG is as effective as corticosteroids in chronic inflammatory demyelinating polyradiculoneuropathy (grade C), and as effective as tacrolimus in Rasmussen syndrome (grade C). IVIG improves recovery in acute disseminated encephalomyelitis (grade C), reduces mortality in acute encephalitis syndrome with myocarditis (grade C), and improves function and stabilizes disease in myasthenia gravis (grade C). IVIG improves outcome in N-methyl-d-aspartate receptor encephalitis (grade C) and opsoclonus-myoclonus syndrome (grade C), reduces cataplexy symptoms in narcolepsy (grade C), speeds recovery in Sydenham chorea (grade C), reduces tics in selected cases of Tourette syndrome (grade D), and improves symptoms in paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (grade B). INTERPRETATION IVIG is a useful therapy in selected neurological conditions. Well-designed, prospective, multi-centre studies with standardized outcome measures are required to compare treatments.
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Affiliation(s)
- Jonathan Gadian
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Emma Kirk
- Evelina London Children's Hospital, St Thomas' Hospital, Paediatric Pharmacy, London, UK
| | | | - Ming Lim
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Absoud
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
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6
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Hacohen Y, Wright S, Gadian J, Vincent A, Lim M, Wassmer E, Lin JP. N-methyl-d-aspartate (NMDA) receptor antibodies encephalitis mimicking an autistic regression. Dev Med Child Neurol 2016; 58:1092-4. [PMID: 27255282 DOI: 10.1111/dmcn.13169] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 12/23/2022]
Abstract
Expressive dysphasia and mutism are common clinical features in children and adults with N-methyl-d-aspartate receptor antibodies (NMDAR-Ab) encephalitis, and are likely to result from NMDAR hypofunction. A prodromal loss of social and communication skills can typify that of an autistic regression, particularly when presenting under the age of 3 years. Here we describe two toddlers who presented with developmental regression, particularly of their social communication skills, mimicking an autistic regression, who were found to have NMDAR-Ab in the serum and cerebrospinal fluid. Although both patients had some other neurological features, they were subtle, which resulted in delayed diagnosis of NMDAR-Ab encephalitis. Importantly, immunotherapy was beneficial in both patients, with significant improvement of their language skills and behaviour.
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Affiliation(s)
- Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Sukhvir Wright
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jonathan Gadian
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ming Lim
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jean-Pierre Lin
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
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Affiliation(s)
- Jonathan Gadian
- Children's Neurosciences, Evelina London Children's Hospital at Guy's & St Thomas' NHS Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's & St Thomas' NHS Trust, Kings Health Partners Academic Health Science Centre, London, UK.,Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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8
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Kariyawasam S, Singh RR, Gadian J, Lumsden DE, Lin JP, Siddiqui A, Hacohen Y, Absoud M, Lim M. Clinical and radiological features of recurrent demyelination following acute disseminated encephalomyelitis (ADEM). Mult Scler Relat Disord 2015; 4:451-456. [PMID: 26346794 DOI: 10.1016/j.msard.2015.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 04/17/2015] [Revised: 06/11/2015] [Accepted: 06/20/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify clinical and radiological features of children that relapse following an initial presentation of acute disseminated encephalomyelitis (ADEM). METHODS Clinical records and neuroimaging of children under the age of 16 years presenting with ADEM to a pediatric neurology referral center between 2006 and 2010 were evaluated. RESULTS Of the 32 children with ADEM, 24 (7 female) with a median age of 4.8 (range 3-15) had a monophasic course. Eight patients (25%; 4 female) with median age of 6.9 (range 3-16) had relapsing demyelination; 3 relapsing within the 3 month interval (still defined within a monophasic event); 4 with multiphasic disseminated encephalomyelitis (MDEM), and 1 with non-multiple sclerosis recurrent demyelination. Clinical features at presentation could not distinguish the monophasic from the relapsing group. Infratentorial imaging changes (brain stem and cerebellar) were seen more frequently in the relapsing group (8/8 vs. 20/24), although differences were not statistically significant. At relapse, seven of the eight patients had clinical and radiologic infratentorial syndromes involving brainstem and/or cerebellum. Only one patient had more than one relapse. After a median follow up of 27 months (range 0-96) across the whole group, no patients were diagnosed with multiple sclerosis. CONCLUSIONS ADEM patients with infratentorial demyelination are more likely to present with a second infratentorial demyelination, although clinical and radiological features at outset could not predict the relapsing cohort.
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Affiliation(s)
- Sanduni Kariyawasam
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Rahul R Singh
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Jonathan Gadian
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Daniel E Lumsden
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Jean-Pierre Lin
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Ata Siddiqui
- Department of Neuroradiology, Kings College Hospital, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Michael Absoud
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK.
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9
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Absoud M, Gadian J, Hellier J, Brex PA, Ciccarelli O, Giovannoni G, Kelly J, McCrone P, Murphy C, Palace J, Pickles A, Pike M, Robertson N, Jacob A, Lim M. Protocol for a multicentre randomiSed controlled TRial of IntraVEnous immunoglobulin versus standard therapy for the treatment of transverse myelitis in adults and children (STRIVE). BMJ Open 2015; 5:e008312. [PMID: 26009577 PMCID: PMC4452744 DOI: 10.1136/bmjopen-2015-008312] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Transverse myelitis (TM) is an immune-mediated disorder of the spinal cord which causes motor and sensory disturbance and limited recovery in 50% of patients. Standard treatment is steroids, and patients with more severe disease appear to respond to plasma exchange (PLEX). Intravenous immunoglobulin (IVIG) has also been used as an adjunct to steroids, but evidence is lacking. We propose the first randomised control trial in adults and children, to determine the benefit of additional treatment with IVIG. METHODS AND ANALYSIS 170 adults and children aged over 1 year with acute first episode TM or neuromyelitis optica (with myelitis) will be recruited over a 2.5-year period and followed up for 12 months. Participants randomised to the control arm will receive standard therapy of intravenous methylprednisolone (IVMP). The intervention arm will receive the above standard therapy, plus additional IVIG. Primary outcome will be a 2-point improvement on the American Spinal Injury Association (ASIA) Impairment scale at 6 months postrandomisation by blinded assessors. Additional secondary and tertiary outcome measures will be collected: ASIA motor and sensory scales, Kurtzke expanded disability status scale, International Spinal Cord Injury (SCI) Bladder/Bowel Data Set, Client Services Receipt Index, Pediatric Quality of Life Inventory, EQ-5D, SCI Pain and SCI Quality of Life Data Sets. Biological samples will be biobanked for future studies. After 6-months' follow-up of the first 52 recruited patients futility analysis will be carried out. Health economics analysis will be performed to calculate cost-effectiveness. After 6 months' recruitment futility analysis will be performed. ETHICS AND DISSEMINATION Research Ethics Committee Approval was obtained: 14/SC/1329. Current protocol: v3.0 (15/01/2015). Study findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS This study is registered with EudraCT (REF: 2014-002335-34), Clinicaltrials.gov (REF: NCT02398994) and ISRCTN (REF: 12127581).
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Affiliation(s)
- M Absoud
- Department of Children's Neurosciences, Evelina Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - J Gadian
- Department of Children's Neurosciences, Evelina Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - J Hellier
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - P A Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - O Ciccarelli
- UCL Institute of Neurology, Queen Square, London, UK
| | - G Giovannoni
- Centre for Neuroscience and Trauma, Blizard Institute, University of London and Bart's Health NHS Trust, London, UK
| | - J Kelly
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - P McCrone
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - C Murphy
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - J Palace
- Department of Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - A Pickles
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M Pike
- Department of Paediatric Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - N Robertson
- Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University and Cardiff and Vale NHS Trust, Cardiff, UK
| | - A Jacob
- The Walton Centre, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - M Lim
- Department of Children's Neurosciences, Evelina Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
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