1
|
Abboud H, Probasco JC, Irani S, Ances B, Benavides DR, Bradshaw M, Christo PP, Dale RC, Fernandez-Fournier M, Flanagan EP, Gadoth A, George P, Grebenciucova E, Jammoul A, Lee ST, Li Y, Matiello M, Morse AM, Rae-Grant A, Rojas G, Rossman I, Schmitt S, Venkatesan A, Vernino S, Pittock SJ, Titulaer MJ. Autoimmune encephalitis: proposed best practice recommendations for diagnosis and acute management. J Neurol Neurosurg Psychiatry 2021; 92:757-768. [PMID: 33649022 PMCID: PMC8223680 DOI: 10.1136/jnnp-2020-325300] [Citation(s) in RCA: 192] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/22/2020] [Accepted: 01/10/2021] [Indexed: 12/18/2022]
Abstract
The objective of this paper is to evaluate available evidence for each step in autoimmune encephalitis management and provide expert opinion when evidence is lacking. The paper approaches autoimmune encephalitis as a broad category rather than focusing on individual antibody syndromes. Core authors from the Autoimmune Encephalitis Alliance Clinicians Network reviewed literature and developed the first draft. Where evidence was lacking or controversial, an electronic survey was distributed to all members to solicit individual responses. Sixty-eight members from 17 countries answered the survey. Corticosteroids alone or combined with other agents (intravenous IG or plasmapheresis) were selected as a first-line therapy by 84% of responders for patients with a general presentation, 74% for patients presenting with faciobrachial dystonic seizures, 63% for NMDAR-IgG encephalitis and 48.5% for classical paraneoplastic encephalitis. Half the responders indicated they would add a second-line agent only if there was no response to more than one first-line agent, 32% indicated adding a second-line agent if there was no response to one first-line agent, while only 15% indicated using a second-line agent in all patients. As for the preferred second-line agent, 80% of responders chose rituximab while only 10% chose cyclophosphamide in a clinical scenario with unknown antibodies. Detailed survey results are presented in the manuscript and a summary of the diagnostic and therapeutic recommendations is presented at the conclusion.
Collapse
Affiliation(s)
- Hesham Abboud
- Neurology, Case Western Reserve University, Cleveland, Ohio, USA .,Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | | | - Sarosh Irani
- Oxford Autoimmune Neurology Group, John Radcliffe Hospital, Oxford, UK
| | - Beau Ances
- Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - David R Benavides
- Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael Bradshaw
- Neurology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Billings Clinic, Billings, Montana, USA
| | - Paulo Pereira Christo
- Neurology, Minas Gerais Federal University Risoleta Tolentino Neves Hospital, Belo Horizonte, MG, Brazil
| | - Russell C Dale
- Neuroimmunology Group, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Mireya Fernandez-Fournier
- Neurology, La Paz University Hospital General Hospital Department of Neurology, Madrid, Madrid, Spain
| | | | - Avi Gadoth
- Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | | | - Soon-Tae Lee
- Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yuebing Li
- Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marcelo Matiello
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Marie Morse
- Pediatric Neurology, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Galeno Rojas
- Neurology, Sanatorio de La Trinidad Mitre, Buenos Aires, Argentina.,Neurology, Favaloro Foundation, Buenos Aires, Argentina
| | - Ian Rossman
- Neuro-developmental Science Center, Akron Children's Hospital, Akron, Ohio, USA
| | | | | | | | | | - Maarten J Titulaer
- Neurology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | |
Collapse
|
2
|
Abboud H, Probasco J, Irani SR, Ances B, Benavides DR, Bradshaw M, Christo PP, Dale RC, Fernandez-Fournier M, Flanagan EP, Gadoth A, George P, Grebenciucova E, Jammoul A, Lee ST, Li Y, Matiello M, Morse AM, Rae-Grant A, Rojas G, Rossman I, Schmitt S, Venkatesan A, Vernino S, Pittock SJ, Titulaer M. Autoimmune encephalitis: proposed recommendations for symptomatic and long-term management. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325302. [PMID: 33649021 PMCID: PMC8292591 DOI: 10.1136/jnnp-2020-325302] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 12/12/2022]
Abstract
The objective of this paper is to evaluate available evidence for each step in autoimmune encephalitis management and provide expert opinion when evidence is lacking. The paper approaches autoimmune encephalitis as a broad category rather than focusing on individual antibody syndromes. Core authors from the Autoimmune Encephalitis Alliance Clinicians Network reviewed literature and developed the first draft. Where evidence was lacking or controversial, an electronic survey was distributed to all members to solicit individual responses. Sixty-eight members from 17 countries answered the survey. The most popular bridging therapy was oral prednisone taper chosen by 38% of responders while rituximab was the most popular maintenance therapy chosen by 46%. Most responders considered maintenance immunosuppression after a second relapse in patients with neuronal surface antibodies (70%) or seronegative autoimmune encephalitis (61%) as opposed to those with onconeuronal antibodies (29%). Most responders opted to cancer screening for 4 years in patients with neuronal surface antibodies (49%) or limbic encephalitis (46%) as opposed to non-limbic seronegative autoimmune encephalitis (36%). Detailed survey results are presented in the manuscript and a summary of the diagnostic and therapeutic recommendations is presented at the conclusion.
Collapse
Affiliation(s)
- Hesham Abboud
- Neurology, Case Western Reserve University, Cleveland, Ohio, USA
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - John Probasco
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, John Radcliffe Hospital, Oxford, UK
| | - Beau Ances
- Neurology, Washington University in St Louis, St Louis, Missouri, USA
| | - David R Benavides
- Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael Bradshaw
- Neurology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
- Neurology, Billings Clinic, Billings, Montana, USA
| | - Paulo Pereira Christo
- Neurology, Minas Gerais Federal University Risoleta Tolentino Neves Hospital, Belo Horizonte, Brazil
| | - Russell C Dale
- Neuroimmunology Group, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | | | - Avi Gadoth
- Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Elena Grebenciucova
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Soon-Tae Lee
- Neurology, Seoul National University College of Medicine, Seoul, The Republic of Korea
| | - Yuebing Li
- Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marcelo Matiello
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Marie Morse
- Pediatric Neurology, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Galeno Rojas
- Neurology, Sanatorio de La Trinidad Mitre, Buenos Aires, Argentina
- Favaloro Foundation, Buenos Aires, Argentina
| | - Ian Rossman
- Neuro-developmental Science Center, Akron Children's Hospital, Akron, Ohio, USA
| | | | | | | | | | - Maarten Titulaer
- Neurology, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| |
Collapse
|
3
|
Abstract
Autoantibody-mediated encephalitis is a heterogeneous group of recently identified disorders, all caused by autoimmunity directed against components of the central nervous system. Despite severe and even prolonged neurologic deficits, dramatic improvements may occur with aggressive treatment.
Collapse
Affiliation(s)
- Adham Jammoul
- Neurohospitalist Program, Department of Specialty Medicine, Aultman Hospital, Canton, OH, USA. E-mail:
| | - Yuebing Li
- Neuromuscular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Alexander Rae-Grant
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.,Clinical Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
4
|
Bencsath K, Jammoul A, Aminian A, Shimizu H, Fisher CJ, Schauer PR, Rae-Grant A, Brethauer SA. Outcomes of Bariatric Surgery in Morbidly Obese Patients with Multiple Sclerosis. J Obes 2017; 2017:1935204. [PMID: 28299203 PMCID: PMC5337361 DOI: 10.1155/2017/1935204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/13/2017] [Accepted: 02/01/2017] [Indexed: 01/08/2023] Open
Abstract
Obesity is common in patients with multiple sclerosis (MS); however, safety and efficacy of bariatric surgery in this population remain unclear. A database of 2,918 was retrospectively reviewed, yielding 22 (0.75%) severely obese patients with MS who underwent bariatric surgery. Sixteen surgical patients with complete follow-up data were matched to a nonsurgical control group of MS patients, based on age, BMI, MS subtype, and length of follow-up. MS relapse rates and trends in the timed twenty-five foot walk test (T25FW) were compared. In the surgical group (gastric bypass n = 19, sleeve gastrectomy n = 3), preoperative BMI was 46.5 ± 7.2 Kg/m2 and average excess weight was 60.4 kg. Follow-up data was collected at 59.0 ± 29.8 months. There were two major and four minor complications. Five patients required readmission and there were no mortalities. Percent excess weight loss was 75.5 ± 27.0%. In the 16 patients with follow-up data, patients who underwent bariatric surgery were significantly faster on the T25FW compared to the nonsurgical population. In conclusion, bariatric surgery is relatively safe and effective in achieving weight loss in patients with MS. In addition, surgery may help patients maintain ambulation. Findings support the need for further studies on bariatric surgery and disease-specific outcomes in this population.
Collapse
Affiliation(s)
- Kalman Bencsath
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
- *Kalman Bencsath:
| | - Adham Jammoul
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hideharu Shimizu
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carolyn J. Fisher
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Philip R. Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alexander Rae-Grant
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stacy A. Brethauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
5
|
Jammoul A, Shayya L, Mente K, Li J, Rae-Grant A, Li Y. Clinical utility of seropositive voltage-gated potassium channel-complex antibody. Neurol Clin Pract 2016; 6:409-418. [PMID: 27847683 DOI: 10.1212/cpj.0000000000000268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antibodies against voltage-gated potassium channel (VGKC)-complex are implicated in the pathogenesis of acquired neuromyotonia, limbic encephalitis, faciobrachial dystonic seizure, and Morvan syndrome. Outside these entities, the clinical value of VGKC-complex antibodies remains unclear. METHODS We conducted a single-center review of patients positive for VGKC-complex antibodies over an 8-year period. RESULTS Among 114 patients positive for VGKC-complex antibody, 11 (9.6%) carrying the diagnosis of limbic encephalitis (n = 9) or neuromyotonia (n = 2) constituted the classic group, and the remaining 103 cases of various neurologic and non-neurologic disorders comprised the nonclassic group. The median titer for the classic group was higher than the nonclassic group (p < 0.0001). A total of 90.9% of the patients in the classic and 21.4% in the nonclassic group possessed high (>0.25 nM) VGKC-complex antibody levels (p < 0.0001). A total of 75.0% of the patients in the high-level group had definite or probable autoimmune basis, while nonautoimmune disorders were seen in 75.6% of patients from the low-level group (p < 0.0001). A total of 26.3% of patients were found with active or remote solid organ or hematologic malignancy, but no antibody titer difference was observed among subgroups of absent, active, or remote malignancy. Compared to age-matched US national census, rates of active cancer in our cohort were higher in patients older than 45 years. CONCLUSIONS High VGKC-complex antibody titers are more likely found in patients with classically associated syndromes and other autoimmune conditions. Low-level VGKC-complex antibodies can be detected in nonspecific and mostly nonautoimmune disorders. The presence of VGKC-complex antibody, rather than its level, may serve as a marker of malignancy.
Collapse
Affiliation(s)
- Adham Jammoul
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Luay Shayya
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Karin Mente
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Jianbo Li
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Alexander Rae-Grant
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| | - Yuebing Li
- Neurohospitalist Program (AJ), Aultman Hospital, Canton; and Department of Neurology (LS, KM, AR-G, YL) and Department of Quantitative Health Sciences, Lerner Research Institute (JL), Cleveland Clinic Foundation, OH
| |
Collapse
|
6
|
Li Y, Jammoul A, Mente K, Li J, Shields RW, Vernino S, Rae-Grant A. Clinical experience of seropositive ganglionic acetylcholine receptor antibody in a tertiary neurology referral center. Muscle Nerve 2015; 52:386-91. [DOI: 10.1002/mus.24559] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/17/2014] [Accepted: 12/19/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Yuebing Li
- Department of Neurology; Desk S90, Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| | - Adham Jammoul
- Department of Neurology; Desk S90, Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| | - Karin Mente
- Department of Neurology; Desk S90, Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| | - Jianbo Li
- Department of Quantitative Health Sciences; Learner Research Institute, Cleveland Clinic Foundation; Cleveland Ohio USA
| | - Robert W. Shields
- Department of Neurology; Desk S90, Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| | - Steven Vernino
- Department of Neurology and Neurotherapeutics; University of Texas Southwestern Medical Center; Dallas Texas USA
| | - Alexander Rae-Grant
- Department of Neurology; Desk S90, Cleveland Clinic Foundation; 9500 Euclid Avenue Cleveland Ohio 44195 USA
| |
Collapse
|
7
|
Abstract
Benign rolandic epilepsy (BRE), childhood idiopathic occipital epilepsy (CIOE), childhood absence epilepsy (CAE), and juvenile myoclonic epilepsy (JME) are some of the common epilepsy syndromes in the pediatric age group. Among the four, BRE is the most commonly encountered. BRE remits by age 16 years with many children requiring no treatment. Seizures in CAE also remit at the rate of approximately 80%; whereas, JME is considered a lifelong condition even with the use of antiepileptic drugs (AEDs). Neonates and infants may also present with seizures that are self-limited with no associated psychomotor disturbances. Benign familial neonatal convulsions caused by a channelopathy, and inherited in an autosomal dominant manner, have a favorable outcome with spontaneous resolution. Benign idiopathic neonatal seizures, also referred to as "fifth-day fits," are an example of another epilepsy syndrome in infants that carries a good prognosis. BRE, CIOE, benign familial neonatal convulsions, benign idiopathic neonatal seizures, and benign myoclonic epilepsy in infancy are characterized as "benign" idiopathic age-related epilepsies as they have favorable implications, no structural brain abnormality, are sensitive to AEDs, have a high remission rate, and have no associated psychomotor disturbances. However, sometimes selected patients may have associated comorbidities such as cognitive and language delay for which the term "benign" may not be appropriate.
Collapse
|
8
|
Jammoul A, Lederman RJ, Tavee J, Li Y. Presence of voltage-gated potassium channel complex antibody in a case of genetic prion disease. BMJ Case Rep 2014; 2014:bcr-2013-201622. [PMID: 24903967 DOI: 10.1136/bcr-2013-201622] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Voltage-gated potassium channel (VGKC) complex antibody-mediated encephalitis is a recently recognised entity which has been reported to mimic the clinical presentation of Creutzfeldt-Jakob disease (CJD). Testing for the presence of this neuronal surface autoantibody in patients presenting with subacute encephalopathy is therefore crucial as it may both revoke the bleak diagnosis of prion disease and allow institution of potentially life-saving immunotherapy. Tempering this optimistic view is the rare instance when a positive VGKC complex antibody titre occurs in a definite case of prion disease. We present a pathologically and genetically confirmed case of CJD with elevated serum VGKC complex antibody titres. This case highlights the importance of interpreting the result of a positive VGKC complex antibody with caution and in the context of the overall clinical manifestation.
Collapse
Affiliation(s)
- Adham Jammoul
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Richard J Lederman
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jinny Tavee
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA Neuromuscular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Yuebing Li
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA Neuromuscular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
9
|
Jammoul A, Hussain M. E-068 Spinal Cord Infarction After Bronchial Artery Embolisation. J Neurointerv Surg 2013. [DOI: 10.1136/neurintsurg-2013-010870.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
10
|
Nieto-Gligorovski L, Net S, Gligorovski S, Zetzsch C, Jammoul A, D’Anna B, George C. Interactions of ozone with organic surface films in the presence of simulated sunlight: impact on wettability of aerosols. Phys Chem Chem Phys 2008; 10:2964-71. [DOI: 10.1039/b717993f] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
11
|
|
12
|
Sala-Mateus C, Enjuanes J, Martínez-Heras P, Romero P, Ballester F, Jammoul A, de Febrer G, Castro A. [Complicated sinusitis in a diabetic patient]. Enferm Infecc Microbiol Clin 1997; 15:107-8. [PMID: 9101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C Sala-Mateus
- Servicio de Medicina Interna, Hospital Universitari de Sant Joan, Reus, Tarragona
| | | | | | | | | | | | | | | |
Collapse
|