Clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children: A case series of 16 patients

PURPOSE

To investigate the clinical characteristics of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy in children.

METHODS

We reviewed the medical records of Children's Hospital of Chongqing Medical University from January 2020 to September 2021 and retrospectively analysed the clinical features, magnetic resonance imaging (MRI) findings, laboratory findings, treatment and outcome of children with autoimmune GFAP astrocytopathy.

RESULTS

Sixteen patients were included: 6 and 10 tested positive for GFAP-IgG in cerebrospinal fluid (CSF) and both CSF and serum, respectively. The median patient age was 115 months (range: 36-180 months), and 7 patients (43.8%) were male. All patients had the clinical syndrome of encephalitis/meningoencephalitis with or without myelitis: encephalitis (8), meningoencephalitis (3), encephalomyelitis (1) and meningoencephalomyelitis (4). The most common clinical symptoms were fever (11), altered consciousness (11), headache (10) and seizure (9). Four patients developed central respiratory failure for which mechanical ventilation was needed. All patients showed hyperintense T2-weighted lesions on brain MRI in the cerebral white matter (13), brainstem (11), basal ganglia (11), thalamus (9), and cerebellum (3). Nine patients (56%) had abnormal hyperintense lesions in the bilateral basal ganglia and thalamus. Six of 12 patients who underwent gadolinium-enhanced brain MRI showed abnormal enhancement images, and five of them showed linear perivascular radial enhancement. The modified Rankin scale (mRS) score decreased significantly in most patients after immunotherapy. Two patients with coexisting neural autoantibodies relapsed; however, 15 patients who were followed up successfully had favorable outcomes at the last follow-up.

CONCLUSION

Children with autoimmune GFAP astrocytopathy usually have a clinical syndrome of encephalitis/meningoencephalitis with or without myelitis. Except for the linear perivascular radial gadolinium enhancement pattern, hyperintense lesions in the bilateral basal ganglia and thalamus might be another characteristic brain MRI finding of autoimmune GFAP astrocytopathy in children. Although a few patients with coexisting neural autoantibodies might relapse, children with autoimmune GFAP astrocytopathy usually have favorable outcomes after immunotherapy.

Orofacial Dyskinesia and Intractable Hiccups in a Patient with Varicella-zoster Virus Encephalomyelitis

A 73-year-old Japanese man with diabetic complications presented with involuntary lip movements and long-lasting hiccups after developing zoster rash. Magnetic resonance imaging revealed lesions involving the medial temporal lobe and C1 level of the spinal cord. Varicella-zoster virus (VZV) encephalomyelitis was diagnosed. We considered attributing the orofacial dyskinesia, a very rare symptom of VZV central nervous system (CNS) complications, to the temporal lobe lesion. Although the culprit lesion for the hiccups was unclear, further examinations may have clarified this issue. As immunocompromised patients with herpes zoster may develop CNS complications with a wide variety of symptoms, special care is needed.

MRI characteristics of Japanese macaque encephalomyelitis: Comparison to human diseases

BACKGROUND AND PURPOSE

To describe MRI findings in Japanese macaque encephalomyelitis (JME) with emphasis on lesion characteristics, lesion evolution, normal-appearing brain tissue, and similarities to human demyelinating disease.

METHODS

MRI data were obtained from 114 Japanese macaques, 30 presenting neurological signs of JME. All animals were screened for presence of T2 -weighted white matter signal hyperintensities; animals with behavioral signs of JME were additionally screened for contrast-enhancing lesions. Whole-brain quantitative T1 maps were collected, and histogram analysis was performed with regression across age to evaluate microstructural changes in normal appearing brain tissue in JME and neurologically normal animals. Quantitative estimates of blood-brain-barrier (BBB) permeability to gadolinium-based-contrast agent (GBCA) were obtained in acute, GBCA-enhancing lesions. Longitudinal imaging data were acquired for 15 JME animals.

RESULTS

One hundred and seventy-three focal GBCA-enhancing lesions were identified in 30 animals demonstrating behavioral signs of neurological dysfunction. JME GBCA-enhancing lesions were typically focal and ovoid, demonstrating highest BBB GBCA permeability in the lesion core, similar to acute, focal multiple sclerosis lesions. New GBCA-enhancing lesions arose rapidly from normal-appearing tissue, and BBB permeability remained elevated for weeks. T1 values in normal-appearing tissue were significantly associated with age, but not with sex or disease.

CONCLUSIONS

Intense, focal neuroinflammation is a key MRI finding in JME. Several features of JME compare directly to human inflammatory demyelinating diseases. Investigation of JME combined with the development and validation of noninvasive imaging biomarkers offers substantial potential to improve diagnostic specificity and contribute to the understanding of human demyelinating diseases.

A case of possible atypical demyelinating event of the central nervous system following COVID-19

After the novel coronavirus disease outbreak first began in Wuhan, China, in December 2019, the viral epidemic has quickly spread across the world, and it is now a major public health concern. Here we present a 21-year-old male with encephalomyelitis following intermittent vomiting and malaise for 4 days. He reported upper respiratory signs and symptoms 2 weeks before this presentation. Two cerebrospinal fluid (CSF) analyses were notable for mononuclear pleocytosis, elevated protein (more than 100 mg/dl), and hypoglycorrhachia. Brain Magnetic Resonance Imaging (MRI) showed bilateral posterior internal capsule lesions extending to the ventral portion of the pons and a marbled splenium hyperintensity pattern. Cervical and thoracic MRI showed longitudinally extensive transverse myelitis (LETM), none of which were enhanced with gadolinium. Both the AQP4 and MOG antibodies were negative. Spiral chest computed tomography (CT) scan confirmed to COVID-19 as did the high IgG level against coronavirus, but the oropharyngeal swabs were negative. Neurological manifestations of COVID-19 have not been adequately studied. Some COVID-19 patients, especially those suffering from a severe disease, are highly likely to have central nervous system (CNS) manifestations. Our case is a post-COVID-19 demyelinating event in the CNS.

MOG encephalomyelitis: distinct clinical, MRI and CSF features in patients with longitudinal extensive transverse myelitis as first clinical presentation

Background

Based on clinical, immunological and histopathological evidence, MOG-IgG-associated encephalomyelitis (MOG-EM) has emerged as a distinct disease entity different from multiple sclerosis (MS) and aquaporin-4-antibody-positive neuromyelitis optica spectrum disorder (NMOSD). MOG-EM is associated with a broader clinical phenotype including optic neuritis, myelitis, brainstem lesions and acute disseminated encephalomyelitis with a substantial clinical and radiological overlap to other demyelinating CNS disorders.

Objective

To evaluate common clinical, MRI and CSF findings, as well as therapy responses in patients with longitudinal extensive transverse myelitis (LETM) as initial clinical presentation of MOG-EM.

Methods

After excluding patients with a known diagnosis of MS, we identified 153 patients with myelitis of which 7 fulfilled the inclusion criteria and were investigated for MRI, CSF and clinical parameters.

Results

Patients with LETM as first clinical presentation of MOG-EM display similar characteristics, namely a lack of gadolinium-enhancement in spinal cord MRI, marked pleocytosis, negative oligoclonal bands, a previous history of infections/vaccinations and response to antibody-depleting treatments for acute attacks and long-term treatment.

Conclusions

We identify common pathological findings in patients with LETM as first clinical presentation of MOG-EM which distinguishes it from other forms of LETM and should lead to testing for MOG-IgG in these cases.

A young woman with seizures, visual impairment, and paralysis

BACKGROUND

Anti-MOG encephalomyelitis is a recently described demyelinating, autoimmune disease of the central nervous system, identified by antibodies against myelin oligodendrocyte glycoprotein (MOG).

CASE PRESENTATION

A previously healthy 20-year-old woman was admitted to hospital after a seizure. MRI showed leptomeningeal enhancement and lumbar puncture revealed moderate pleocytosis but no evidence of infection. Over the following months, she experienced a series of neurological deficits including bladder dysfunction, loss of sensation in the lower extremities and genital area, impaired motor function of the legs and episodes of visual loss. All symptoms had MRI correlates in the medulla, brainstem, optic tract, thalami and corpus callosum. She responded excellently to corticosteroid treatment, but experienced relapses shortly after discontinuation of treatment. Repeated lumbar puncture revealed pleocytosis up to 475 ∙ 106 cells/l but there were no signs of intrathecal IgG synthesis or infection. Serum anti-MOG antibodies were detected two months after the initial episode. She has been treated with low dose corticosteroids in combination with rituximab for two years, without clinical or radiological relapse.

INTERPRETATION

Symptoms and signs mimicking acute demyelinating encephalomyelitis and neuromyelitis optica are typical for anti-MOG encephalomyelitis. This case illustrates that the response to corticosteroids may be excellent but transient, and that the disease can be controlled with moderate immunosuppression.

Etiologic spectrum and functional outcome of the acute inflammatory myelitis

Clinical, neuroimaging, and laboratory features are not specific enough to establish the etiological diagnosis of the acute inflammatory myelitis (AIM). Longitudinally extensive transverse myelitis (LETM) seen on magnetic resonance imaging (MRI) has been associated with a poor functional prognosis. The aim of this study was to assess the functional outcomes of a first AIM event comparing patients with LETM vs. no LETM on MRI and to report the differential diagnosis. Clinical, radiological, biochemical aspects were collected, and Winner-Hughes Functional Disability Scale (WHFDS) was performed after 3 and 6 months. Centromedullary lesions were associated with LETM, lateral lesions with partial lesion (PL), and brain MRI lesions with multiple sclerosis and acute encephalomyelitis disseminated. LETM patients were associated with a worse functional outcome as the need of a wheelchair after 3 and 6 months (OR = 7.61 p = 0.01; OR 4.8 p = 0.04, respectively), a walker or cane (OR = 11.0 p = 0.002, OR = 4.3 p = 0.03, respectively). In addition, we found a correlation between LETM and acute complete transverse myelitis and PL with acute partial transverse myelitis (83.3 and 90.9%, respectively; p < 0.0001). In conclusion, AIM is a heterogeneous syndrome from an etiological point of view and LETM patients had worse functional prognosis compared with PL after 3 and 6 months.

Acute disseminated encephalomyelitis associated with hepatitis A virus infection

We describe the case of a 30-month-old boy who developed acute disseminated encephalomyelitis (ADEM) after hepatitis A virus (HAV) infection and ultimately died. As far as we know, this is only the second case of HAV-associated ADEM to be reported in the literature. The child was brought to hospital with fever, lethargy and weakness of 2 days duration. He had developed jaundice, abdominal pain and malaise 2 weeks beforehand and these problems had resolved within 2 days. Neurological examination revealed lethargy, generalised weakness and positive Babinski's signs bilaterally. Cerebrospinal fluid examination showed mild lymphocytic pleocytosis, increased protein and elevated anti-HAV IgM and IgG titres. Serum HAV IgM and IgG titres were also elevated. Despite aggressive treatment with ceftriaxone, acyclovir and anti-oedema measures, he developed papilloedema and coma within 24 hours of admission. Magnetic resonance imaging of the brain revealed diffuse cerebral oedema and multifocal hyperintensities on T2-weighted images, with most lesions in the white matter of both cerebral hemispheres. The diagnosis of ADEM was established and high-dose steroids and intravenous immunoglobulin were added to the treatment regimen. However, his clinical condition continued to deteriorate and he died on the 20th day in hospital. This case shows that HAV infection can be linked with ADEM. Patients with HAV infection should be examined carefully for central nervous system symptoms during follow-up. Likewise, the possibility of HAV infection should be investigated in cases of ADEM.

Case report: primary infection by human herpesvirus 6 variant a with the onset of myelitis

A case of primary infection by human herpesvirus 6 (HHV-6) variant A in a 54-year-old woman, which occurred at the same time as the onset of encephalomyelitis, is reported. The correlation between the two events is discussed. It is speculated that, during the early phase of the infection, the HHV-6 spread to the central nervous system and triggered a pathogenic process that initially developed without symptoms. When the neurological disorders appeared, HHV-6 had already established a latent state: only the virus carried by infected blood cells was detected in the cerebrospinal fluid.

Bilateral, reversible, selective thalamic involvement demonstrated by brain MR and acute severe neurological dysfunction with favorable outcome

We report on two children who presented acute, severe, neurological dysfunction with bilateral, reversible, selective thalamic lesions demonstrated by brain MRI. In both children neurological symptoms appeared two weeks after a febrile respiratory illness. Clinical conditions worsened in a few days to a stuporous state and tetraplegia in one and to coma with decerebrate posturing in the other. Three weeks after the onset, both children improved and recovered within one month. During the acute phase, brain MRI showed in both children bilateral hyperintense areas on T2-weighted sequences limited to both thalamic regions. During the follow-up, repeated brain MRI showed complete disappearance of abnormalities in one patient and a small residual left thalamic lesion in the other. In both patients hematological routine exams were normal. Bacterial and viral studies of serum and CSF were negative. CSF findings showed elevated white blood cell count and protein levels, with no oligoclonal IgG bands. Urine and CSF organic acids by GC/MS and plasma as well as CSF amino acids were normal. We believe that the benign evolution of this disorder and CSF findings strongly suggest a postinfectious process of the central nervous system.

The radiographic diagnosis and treatment of paraneoplastic central nervous system disease

Paraneoplastic nervous system syndromes are being identified with increasing frequency because of greater physician awareness and the availability of serodiagnostic tests for some syndromes. Frequently, paraneoplastic syndromes develop in the setting of an indolent, limited stage, or otherwise occult malignancy. As a result, the paraneoplastic disorder often becomes the most disabling part of a patient's disease. Effective treatment appears to require early identification. For these reasons, the ability to diagnose a paraneoplastic syndrome, follow its course, and treat it successfully are important. The authors describe four patients with neurologic paraneoplastic syndromes and identical magnetic resonance imaging abnormalities. Three patients responded to immunosuppressive or immunomodulatory therapy, and in one, corresponding radiographic improvement was documented. Strategies for early diagnosis and options for treatment of paraneoplastic nervous system disorders are discussed.

[Positron emission tomography in acute disseminated encephalomyelitis: a case report]

Sequential positron emission tomography (PET) and single photon emission tomography (SPECT) were performed in an 11-year-old girl who was clinically diagnosed as acute disseminated encephalomyelitis (ADEM). She had fever, stupor, loss of sight and left hemiparesis on admission to our hospital. X-ray CT (XCT) demonstrated a hypodense lesion in the right fronto-parietal white matter. In the 1st PET study, CBF and CMRO2 were reduced in both hemispheric white and gray matter, particularly in the right fronto-parietal lesion. The XCT abnormality was improved in the subsequent scan when the patient had improved except visual disturbance. When visual disturbance was worsened again, and a new hypodense lesion was appeared in the left frontal white matter on XCT, the 2nd PET study was performed. CBF and CMRO2 were recovered except the left frontal white and gray matter. SPECT study was also performed and the image was almost similar to CBF image of PET scan. The changes and distributions of CBF and CMRO2 were related to her symptoms and clinical course. Reduced CBF and CMRO2 of whole brain is thought to be characteristic of ADEM. From the experiences of this case, PET measurements is useful for the understanding of neuronal functional abnormalities of ADEM, and is more useful for the detection of recovery or relapsing process than XCT.

Postinfectious encephalomyelitis with localized basal ganglia involvement

The diagnosis of postinfectious encephalomyelitis with symmetric lesions in the basal ganglia was confirmed by magnetic resonance imaging in 2 patients. A 7-year-old patient experienced severe dystonia and hyperreflexia; magnetic resonance imaging demonstrated bilateral lesions in the putamina and basis pontes. The other patient, a 2-year-old female, manifested hypotonia, facial grimacing, and athetosis. Symmetric lesions in the globus pallidus and substantia nigra were demonstrated by imaging studies. The nature and monophasic course of illness in these 2 patients, as well as the symmetric involvement of specific regions of the basal ganglia, may result from an immune-mediated postinfectious demyelinating process.

Serial cerebral CT abnormalities in relapsing acute disseminated encephalomyelitis

A 7 year old girl developed acute disseminated encephalomyelitis following a Mycoplasma pneumoniae respiratory infection. The illness followed a relapsing course during the first two months. Computed tomography (CT) showed cerebral lesions of a severity and extent out of proportion to the clinical manifestations. The CT abnormalities altered with changes in her clinical state.

Cranial computed tomography in acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an uncommon inflammatory disorder of the nervous system. The appearance of ADEM on cranial CT scans has rarely been reported. The author reports seven cases in two institutions during a period of seven years. Only four of the seven patients had hypodense lesions in the white matter and six patients showed spotty, nodular, or gyral enhancement after contrast injections. The enhancement resolved with steroid therapy, leaving some persistent hypoattenuated areas even after 10 months follow-up, these findings support the dual components of the pathogenesis of ADEM. The vasculitic component may be responsive to steroids, nevertheless the demyelinating or necrotic areas may not, and the latter may be responsible for the sequelae of ADEM.

Computed tomography in acute disseminated encephalomyelitis

Computed tomographic (CT) scans were obtained for eleven patients with acute disseminated encephalomyelitis (ADE). Four patients had normal CT scans despite repeated examination. Abnormalities were found in seven patients and included cortical-enhancing lesions, low-density lesions in the deep white matter and basal ganglia, and edema of the brainstem. These findings support the hypothesis that both vascular injury and demyelination are involved in the pathogenesis of ADE. A delay between the onset of clinical signs and the appearance of lesions on CT scan was common. Clinical improvement was accompanied by improvement in CT abnormalities. There was a limited correlation between the clinical course and the anatomical distribution and type of abnormality seen on CT scan.

Reversible multiple hypodense areas in the white matter diagnosed as acute disseminated encephalomyelitis

A case of multiple, computed tomographic areas of hypodensity in the cerebral white matter was diagnosed as acute disseminated encephalomyelitis. The low density area regressed, and the 5-year-old patient improved after steroid treatment.