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1.
Neurol Neuroimmunol Neuroinflamm ; 11(4): e200225, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38838283

RESUMO

BACKGROUND AND OBJECTIVES: Patients with ongoing seizures are usually not allowed to drive. The prognosis for seizure freedom is favorable in patients with autoimmune encephalitis (AIE) with antibodies against NMDA receptor (NMDAR), leucine-rich glioma-inactivated 1 (LGI1), contactin-associated protein-like 2 (CASPR2), and the gamma-aminobutyric-acid B receptor (GABABR). We hypothesized that after a seizure-free period of 3 months, patients with AIE have a seizure recurrence risk of <20% during the subsequent 12 months. This would render them eligible for noncommercial driving according to driving regulations in several countries. METHODS: This retrospective multicenter cohort study analyzed follow-up data from patients aged 15 years or older with seizures resulting from NMDAR-, LGI1-, CASPR2-, or GABABR-AIE, who had been seizure-free for ≥3 months. We used Kaplan-Meier (KM) estimates for the seizure recurrence risk at 12 months for each antibody group and tested for the effects of potential covariates with regression models. RESULTS: We included 383 patients with NMDAR-, 440 with LGI1-, 114 with CASPR2-, and 44 with GABABR-AIE from 14 international centers. After being seizure-free for 3 months after an initial seizure period, we calculated the probability of remaining seizure-free for another 12 months (KM estimate) as 0.89 (95% confidence interval [CI] 0.85-0.92) for NMDAR, 0.84 (CI 0.80-0.88) for LGI1, 0.82 (CI 0.75-0.90) for CASPR2, and 0.76 (CI 0.62-0.93) for GABABR. DISCUSSION: Taking a <20% recurrence risk within 12 months as sufficient, patients with NMDAR-AIE and LGI1-AIE could be considered eligible for noncommercial driving after having been seizure-free for 3 months.


Assuntos
Autoanticorpos , Encefalite , Peptídeos e Proteínas de Sinalização Intracelular , Proteínas de Membrana , Proteínas do Tecido Nervoso , Receptores de GABA-B , Recidiva , Humanos , Feminino , Masculino , Adulto , Peptídeos e Proteínas de Sinalização Intracelular/imunologia , Autoanticorpos/sangue , Pessoa de Meia-Idade , Encefalite/imunologia , Estudos Retrospectivos , Receptores de GABA-B/imunologia , Proteínas do Tecido Nervoso/imunologia , Adulto Jovem , Proteínas de Membrana/imunologia , Receptores de N-Metil-D-Aspartato/imunologia , Convulsões/etiologia , Convulsões/imunologia , Doença de Hashimoto/imunologia , Doença de Hashimoto/sangue , Idoso , Adolescente , Seguimentos , Proteínas/imunologia , Estudos de Coortes
2.
JAMA Neurol ; 81(5): 525-533, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38497971

RESUMO

Importance: Rapid and accurate diagnosis of autoimmune encephalitis encourages prompt initiation of immunotherapy toward improved patient outcomes. However, clinical features alone may not sufficiently narrow the differential diagnosis, and awaiting autoantibody results can delay immunotherapy. Objective: To identify simple magnetic resonance imaging (MRI) characteristics that accurately distinguish 2 common forms of autoimmune encephalitis, LGI1- and CASPR2-antibody encephalitis (LGI1/CASPR2-Ab-E), from 2 major differential diagnoses, viral encephalitis (VE) and Creutzfeldt-Jakob disease (CJD). Design, Setting, and Participants: This cross-sectional study involved a retrospective, blinded analysis of the first available brain MRIs (taken 2000-2022) from 192 patients at Oxford University Hospitals in the UK and Mayo Clinic in the US. These patients had LGI1/CASPR2-Ab-E, VE, or CJD as evaluated by 2 neuroradiologists (discovery cohort; n = 87); findings were validated in an independent cohort by 3 neurologists (n = 105). Groups were statistically compared with contingency tables. Data were analyzed in 2023. Main Outcomes and Measures: MRI findings including T2 or fluid-attenuated inversion recovery (FLAIR) hyperintensities, swelling or volume loss, presence of gadolinium contrast enhancement, and diffusion-weighted imaging changes. Correlations with clinical features. Results: Among 192 participants with MRIs reviewed, 71 were female (37%) and 121 were male (63%); the median age was 66 years (range, 19-92 years). By comparison with VE and CJD, in LGI1/CASPR2-Ab-E, T2 and/or FLAIR hyperintensities were less likely to extend outside the temporal lobe (3/42 patients [7%] vs 17/18 patients [94%] with VE; P < .001, and 3/4 patients [75%] with CJD; P = .005), less frequently exhibited swelling (12/55 [22%] with LGI1/CASPR2-Ab-E vs 13/22 [59%] with VE; P = .003), and showed no diffusion restriction (0 patients vs 16/22 [73%] with VE and 8/10 [80%] with CJD; both P < .001) and rare contrast enhancement (1/20 [5%] vs 7/17 [41%] with VE; P = .01). These findings were validated in an independent cohort and generated an area under the curve of 0.97, sensitivity of 90%, and specificity of 95% among cases with T2/FLAIR hyperintensity in the hippocampus and/or amygdala. Conclusions and Relevance: In this study, T2 and/or FLAIR hyperintensities confined to the temporal lobes, without diffusion restriction or contrast enhancement, robustly distinguished LGI1/CASPR2-Ab-E from key differential diagnoses. These observations should assist clinical decision-making toward expediting immunotherapy. Their generalizability to other forms of autoimmune encephalitis and VE should be examined in future studies.


Assuntos
Autoanticorpos , Encefalite , Peptídeos e Proteínas de Sinalização Intracelular , Imageamento por Ressonância Magnética , Proteínas de Membrana , Proteínas do Tecido Nervoso , Humanos , Masculino , Feminino , Idoso , Peptídeos e Proteínas de Sinalização Intracelular/imunologia , Pessoa de Meia-Idade , Imageamento por Ressonância Magnética/métodos , Estudos Transversais , Autoanticorpos/imunologia , Encefalite/diagnóstico por imagem , Encefalite/imunologia , Encefalite/patologia , Estudos Retrospectivos , Proteínas do Tecido Nervoso/imunologia , Proteínas de Membrana/imunologia , Adulto , Idoso de 80 Anos ou mais , Síndrome de Creutzfeldt-Jakob/diagnóstico por imagem , Síndrome de Creutzfeldt-Jakob/imunologia , Síndrome de Creutzfeldt-Jakob/patologia , Diagnóstico Diferencial , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Doença de Hashimoto/diagnóstico por imagem , Doença de Hashimoto/imunologia , Adulto Jovem
3.
Trans R Soc Trop Med Hyg ; 116(10): 959-965, 2022 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-35385878

RESUMO

BACKGROUND: The importance of autoimmune encephalitis and its overlap with infectious encephalitides are not well investigated in South-East Asia. METHODS: We report autoantibody testing, using antigen-specific live cell-based assays, in a series of 134 patients (cerebrospinal fluid and sera) and 55 blood donor controls (sera), undergoing lumbar puncture for suspected meningoencephalitis admitted in Vientiane, Lao People's Democratic Republic (PDR). RESULTS: Eight of 134 (6%) patients showed detectable serum neuronal autoantibodies, against the N-methyl-D-aspartate and gamma-aminobutyric acid A receptors (NMDAR and GABAAR), and contactin-associated protein-like 2 (CASPR2). Three of eight patients had accompanying autoantibodies in cerebrospinal fluid (two with NMDAR and one with GABAAR antibodies), and in two of these the clinical syndromes were typical of autoimmune encephalitis. Three of the other five patients had proven central nervous system infections, highlighting a complex overlap between diverse infectious and autoimmune causes of encephalitis. No patients in this cohort were treated with immunotherapy, and the outcomes were poor, with improvement observed in a single patient. CONCLUSIONS: In Lao PDR, autoimmune encephalitis is underdiagnosed and has a poor prognosis. Empiric immunotherapy should be considered after treatable infectious aetiologies are considered unlikely. Awareness and diagnostic testing resources for autoimmune encephalitis should be enhanced in South-East Asia.


Assuntos
Encefalite , Meningoencefalite , Autoanticorpos/líquido cefalorraquidiano , Contactinas , Doença de Hashimoto , Humanos , Laos/epidemiologia , Meningoencefalite/diagnóstico , N-Metilaspartato , Receptores de GABA-A , Receptores de N-Metil-D-Aspartato , Ácido gama-Aminobutírico
4.
Ann Neurol ; 90(4): 683-690, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34370313

RESUMO

Pain is a under-recognized association of leucine-rich glioma-inactivated 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) antibodies. Of 147 patients with these autoantibodies, pain was experienced by 17 of 33 (52%) with CASPR2- versus 20 of 108 (19%) with LGI1 antibodies (p = 0.0005), and identified as neuropathic in 89% versus 58% of these, respectively. Typically, in both cohorts, normal nerve conduction studies and reduced intraepidermal nerve fiber densities were observed in the sampled patient subsets. In LGI1 antibody patients, pain responded to immunotherapy (p = 0.008), often rapidly, with greater residual patient-rated impairment observed in CASPR2 antibody patients (p = 0.019). Serum CASPR2 antibodies, but not LGI1 antibodies, bound in vitro to unmyelinated human sensory neurons and rodent dorsal root ganglia, suggesting pathophysiological differences that may underlie our clinical observations. ANN NEUROL 2021;90:683-690.


Assuntos
Autoanticorpos/metabolismo , Proteínas de Membrana/metabolismo , Proteínas do Tecido Nervoso/metabolismo , Neuralgia/imunologia , Neuralgia/metabolismo , Autoanticorpos/imunologia , Moléculas de Adesão Celular Neuronais/imunologia , Moléculas de Adesão Celular Neuronais/metabolismo , Humanos , Peptídeos e Proteínas de Sinalização Intracelular/metabolismo , Canais de Potássio de Abertura Dependente da Tensão da Membrana/imunologia
5.
Pract Neurol ; 21(5): 412-423, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34108243

RESUMO

Autoimmune encephalitis defines brain inflammation caused by a misdirected immune response against self-antigens expressed in the central nervous system. It comprises a heterogeneous group of disorders that are at least as common as infectious causes of encephalitis. The rapid and ongoing expansion of this field has been driven by the identification of several pathogenic autoantibodies that cause polysymptomatic neurological and neuropsychiatric diseases. These conditions often show highly distinctive cognitive, seizure and movement disorder phenotypes, making them clinically recognisable. Their early identification and treatment improve patient outcomes, and may aid rapid diagnosis of an underlying associated tumour. Here we summarise the well-known autoantibody-mediated encephalitis syndromes with neuronal cell-surface antigens. We focus on practical aspects of their diagnosis and treatment, offer our clinical experiences of managing such cases and highlight more basic neuroimmunological advances that will inform their future diagnosis and treatments.


Assuntos
Encefalite , Doença de Hashimoto , Transtornos dos Movimentos , Autoanticorpos , Encefalite/diagnóstico , Encefalite/terapia , Doença de Hashimoto/diagnóstico , Doença de Hashimoto/terapia , Humanos
6.
Can J Neurol Sci ; 48(3): 344-348, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32959754

RESUMO

BACKGROUND/OBJECTIVE: A Canadian Stroke Best Practices consensus statement on Acute Stroke Management during pregnancy was published in 2018. The state of individual practice, however, is unknown. METHODS: A survey on treatment of acute stroke in pregnant and post-partum women was distributed via the Canadian Stroke Consortium email list. Descriptive statistics (frequencies and proportions) were calculated for demographic and response variables and free-text responses were coded for thematic content. RESULTS: Thirty-five participants completed the survey; 12 had experience with intravenous tissue plasminogen activator (IV-tPA), endovascular therapy (EVT), or both in pregnant patients. None had treatment-related complications. The majority (92%) of those who had not yet encountered the issue in practice expressed some reservation about giving IV-tPA to an otherwise eligible pregnant woman. In a theoretical scenario where an otherwise eligible pregnant woman was a candidate for both IV-tPA and EVT, 58% of respondents would have opted for EVT alone. Amongst this cohort comprised mainly of stroke sub-specialists, more than a third had treated pregnant patients with reperfusion therapy. CONCLUSIONS: The reported safety experience with both IV-tPA and EVT was reassuring. Overall, there was a hesitancy towards use of IV-tPA in pregnancy that is discordant with the recent consensus statement. Possible barriers to uptake identified through thematic analysis were concerns regarding risks of bleeding in the pregnant patient, presence of EVT as a perceived alternative, and the need for express consent from the patient and family.


Assuntos
Isquemia Encefálica , Procedimentos Endovasculares , Acidente Vascular Cerebral , Isquemia Encefálica/tratamento farmacológico , Canadá , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Período Pós-Parto , Gravidez , Reperfusão , Acidente Vascular Cerebral/tratamento farmacológico , Inquéritos e Questionários , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
9.
Endocrinology ; 155(10): 3843-52, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25051434

RESUMO

The contribution of peroxisomal proliferator-activated receptor (PPAR)-γ agonism in pancreatic ß-cells to the antidiabetic actions of thiazolidinediones has not been clearly elucidated. Genetic models of pancreatic ß-cell PPARγ ablation have revealed a potential role for PPARγ in ß-cell expansion in obesity but a limited role in normal ß-cell physiology. Here we overexpressed PPARγ1 or PPARγ2 specifically in pancreatic ß-cells of mice subjected to high-fat feeding using an associated adenovirus (ß-PPARγ1-HFD and ß-PPARγ2-HFD mice). We show ß-cell-specific PPARγ1 or PPARγ2 overexpression in diet-induced obese mice exacerbated obesity-induced glucose intolerance with decreased ß-cell mass, increased islet cell apoptosis, and decreased plasma insulin compared with obese control mice (ß-eGFP-HFD mice). Analysis of islet lipid composition in ß-PPARγ2-HFD mice revealed no significant changes in islet triglyceride content and an increase in only one of eight ceramide species measured. Interestingly ß-PPARγ2-HFD islets had significantly lower levels of lysophosphatidylcholines, lipid species shown to enhance insulin secretion in ß-cells. Gene expression profiling revealed increased expression of uncoupling protein 2 and genes involved in fatty acid transport and ß-oxidation. In summary, transgenic overexpression of PPARγ in ß-cells in diet-induced obesity negatively impacts whole-animal carbohydrate metabolism associated with altered islet lipid content, increased expression of ß-oxidative genes, and reduced ß-cell mass.


Assuntos
Intolerância à Glucose/genética , Células Secretoras de Insulina/metabolismo , Células Secretoras de Insulina/patologia , Ilhotas Pancreáticas/metabolismo , Metabolismo dos Lipídeos/genética , Obesidade/complicações , PPAR gama/genética , Animais , Metabolismo dos Carboidratos/genética , Contagem de Células , Células Cultivadas , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Transgênicos , Obesidade/genética , Obesidade/metabolismo , Obesidade/patologia , Especificidade de Órgãos/genética , PPAR gama/metabolismo , Regulação para Cima/genética
10.
Exp Physiol ; 98(2): 564-75, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23042378

RESUMO

Lipotoxicity is implicated in pancreatic ß-cell dysfunction in obesity-induced type 2 diabetes. In vitro, activation of peroxisome proliferator-activated receptor α (PPARα) has been shown to protect pancreatic ß-cells from the lipotoxic effects of palmitate, thereby preserving insulin secretion. Utilizing an adeno-associated virus (dsAAV8), overexpression of PPARα was induced specifically in pancreatic ß-cells of adult, C57Bl/6 mice fed a high-fat diet for 20 weeks and carbohydrate metabolism and ß-cell mass assessed. We show that overexpression of PPARα in pancreatic ß-cells in vivo preserves ß-cell function in obesity, and this improves glucose tolerance by preserving insulin secretion in comparison to control mice with diet-induced obesity. No changes in ß-cell mass were observed in PPARα-overexpressing mice compared with diet-induced obese control animals. This model of ß-cell-specific PPARα overexpression provides a useful in vivo model for elucidating the mechanisms underlying ß-cell lipotoxicity in obesity-induced type 2 diabetes.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Dieta Hiperlipídica , Terapia Genética , Células Secretoras de Insulina/metabolismo , Obesidade/terapia , PPAR alfa/metabolismo , Animais , Glicemia/metabolismo , Linhagem Celular Tumoral , Dependovirus/genética , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/etiologia , Diabetes Mellitus Tipo 2/genética , Diabetes Mellitus Tipo 2/fisiopatologia , Modelos Animais de Doenças , Progressão da Doença , Terapia Genética/métodos , Vetores Genéticos , Insulina/sangue , Resistência à Insulina , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Obesidade/sangue , Obesidade/etiologia , Obesidade/genética , Obesidade/fisiopatologia , PPAR alfa/genética , Fenótipo , Fatores de Tempo , Transfecção , Regulação para Cima
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