Journal of Neuroimmunology 274 (2014) 209–214
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Non-stiff anti-amphiphysin syndrome: Clinical manifestations and outcome after immunotherapy Jangsup Moon a,b,1, Soon-Tae Lee a,b,1, Jung-Won Shin a,b, Jung-Ick Byun a,b, Jung-Ah Lim a,b, Yong-Won Shin a,b, Tae-Joon Kim a,b, Keon-Joo Lee a,b, Kyung-Il Park c, Keun-Hwa Jung a,b, Ki-Young Jung a,b, Sang Kun Lee a,b, Kon Chu a,b,⁎ a b c
Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Department of Neurology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, South Korea
a r t i c l e
i n f o
Article history: Received 15 May 2014 Received in revised form 13 July 2014 Accepted 16 July 2014 Keywords: Anti-amphiphysin antibody Paraneoplastic neurological syndrome Stiff-person syndrome Immunotherapy rituximab
a b s t r a c t Amphiphysin antibody causes paraneoplastic stiff-person syndrome and can also result in a variety of neurological manifestations. Here, we investigated the clinical spectrum of 20 patients with non-stiff anti-amphiphysin syndrome and their responses to immunotherapy. The most common neurological manifestation was limbic encephalitis (n = 10), followed by dysautonomia (n = 9), and cerebellar dysfunction (n = 6). Cancer was detected in only seven patients. Intravenous immunoglobulin or steroid treatment was effective in most patients, but three improved only after rituximab treatment. Our study suggests that anti-amphiphysin syndrome can manifest as non-stiff encephalomyelitis and is only partially associated with cancer. Active immunotherapy, including rituximab, would be beneficial. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Amphiphysin is an intracellular synaptic vesicle protein discovered in 1992 (Lichte et al., 1992) that is involved in retrieving vesicle membranes from the axon terminal's plasma membrane after exocytosis of neurotransmitters (Coppens et al., 2006). Amphiphysin antibody was initially described in patients with paraneoplastic stiff-person syndrome (SPS) (De Camilli et al., 1993), but it was later found in many other types of paraneoplastic neurological syndromes (Pittock et al., 2005). Several case reports and small case series have demonstrated that amphiphysin autoimmunity is associated with limbic encephalitis (Dorresteijn et al., 2002; Krishna et al., 2012), brainstem encephalitis (Coppens et al., 2006), myelopathy (Chamard et al., 2011; Flanagan et al., 2011), peripheral neuropathy (Antoine et al., 1999; Perego et al., 2002; Coppens et al., 2006) and cerebellar dysfunction (Coppens et al., 2006). In 2005, Pittock and colleagues reported SPS in 18 of 63 patients
⁎ Corresponding author at: Department of Neurology, Seoul National University Hospital, 101 Daehang-no, Chongro-gu, Seoul 110-744, South Korea. Tel.: +82 2 2072 1878; fax: +82 2 2072 7424. E-mail address: [email protected] (K. Chu). 1 The first two authors contributed equally to this work.
http://dx.doi.org/10.1016/j.jneuroim.2014.07.011 0165-5728/© 2014 Elsevier B.V. All rights reserved.
(28.6%) with amphiphysin autoimmunity, most of whom had non-stiff encephalomyelitis (Pittock et al., 2005). In addition, according to the report, about 80% of the patients had cancer and about three-fourths had coexisting paraneoplastic antibodies. To date, only a few reports have shown favorable effects of immunotherapy in amphiphysin-related SPS (Murinson and Guarnaccia, 2008; Dupond et al., 2010). Data on the effect of immunotherapy in non-stiff anti-amphiphysin syndrome (NSAS), however, are very limited. In this study, we describe the clinical features in 20 NSAS patients caused by amphiphysin autoimmunity and the outcome of treatment with immunotherapy. 2. Methods This study was conducted at Seoul National University Hospital, a tertiary referral hospital, and was approved by its institutional review board. Between October 2012 and March 2014, patients with possible paraneoplastic syndrome (limbic encephalitis, brainstem encephalitis, cerebellar ataxia, dysautonomia, or polyneuropathy of unknown etiology) were screened for classical paraneoplastic (nuclear or cytoplasmic) or autoimmune synaptic antibodies. Amphiphysin antibody was detected by immunoblotting. Briefly, diluted patient's serum (1:10 to 1:100) or cerebrospinal fluid (1:10) was incubated with recombinant amphiphysin protein and detected by anti-human IgG using an immunoblotting kit (Euroimmun AG,
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Lübeck, Germany). Samples were also tested for the following classical paraneoplastic antibodies and autoimmune synaptic antibodies using detection kits (Euroimmun): anti-Hu, anti-Yo, anti-Ri, anti-Ma2, anti-CV2/CRMP, anti-NMDA receptor, anti-LGI1, anti-Caspr2, antiAMPA1 receptor, anti-AMPA2 receptor, and anti-GABA-b receptor (Shin et al., 2013). Patients who were positive for amphiphysin antibody were included in the analysis. For each patient, the following information was recorded: clinical features, laboratory findings, cerebrospinal fluid profile, electroencephalogram, brain magnetic resonance imaging, nerve conduction study and electromyogram, fluoro-deoxyglucose positron emission tomography, and other radiologic screening tests for detecting systemic neoplasm. 3. Results 3.1. Clinical features of anti-amphiphysin syndrome Between October 2012 and March 2014, amphiphysin antibody was identified in the serum of 20 patients (12 men, eight women; mean age, 57.6 ± 17.2 years). Ten patients were diagnosed with limbic encephalitis, nine with dysautonomia, six with cerebellar dysfunction, and four with brainstem encephalitis. Four patients had peripheral neuropathy and one had myelitis (Table 1). Brain MRI was performed in every patients, which revealed parenchymal T2 high signal intensity (HSI) lesions in three patients and leptomeningeal enhancement in two patients. One patient had T2 HSI lesion in upper cervical spinal cord. CSF pleocytosis was present in four patients. Four patients showed polyneuropathy in nerve conduction studies (Table 2). Cancer was detected in seven patients (35%), which included nonsmall cell lung cancer (n = 1), small cell lung cancer (n = 1), ovarian cancer (n = 1), cervical cancer (n = 1), esophageal cancer (n = 1), and gastric cancer (n = 2). To check for hidden malignancies in rest of the patients, chest and abdomen computed tomography or whole body fluoro-deoxyglucose positron emission tomography was performed in all but one patient (case #19), but no additional cancer was detected (Table 2). Patients with cancer were, on average, older than patients without cancer (mean = 71.1 vs. 50.2 years) (Table 3).
Among the seven patients diagnosed with cancer, four developed neurological symptoms after (mean time, 5.5 months [range, 2–11]) and three before the diagnosis of cancer. In two cases (cases #4 and #7), cancer was detected during the diagnostic workup for the patient's neurological symptoms. In another (case #5), gait disturbance and orthostatic dizziness were detected 1.5 years before the diagnosis of cancer, and psychotic symptoms appeared 1 month after its detection. In the 13 patients without cancer, neurological symptoms lasted for an average of 32.2 months (range, 2–132). Interestingly, one patient (case #16) had been treated by a psychiatric department for 10 years for psychotic symptoms before amphiphysin antibody was detected. In two patients, amphiphysin antibodies were detected after prior history of Epstein–Barr virus encephalitis (Table 1). One patient (case #11) initially experienced fever followed by progressive dizziness, dysarthria, spasticity of one leg, and confusion. The other patient (case #20) first complained of progressive headache and dizziness, and later developed brainstem dysfunction and ataxia. In both patients, EBV infections were confirmed by viral PCR of CSF samples and amphiphysin antibodies were revealed more than one month after the onset of initial symptoms. Additional autoantibodies (Hu, Yo, Ri, and NMDA antibodies) were detected in four patients (cases #3, #7, #16 and #20) (Table 2). 3.2. Effect of treatment Thirteen patients were treated with immunotherapy, which included intravenous immunoglobulin (IVIG) (n = 12), corticosteroids (n = 9), tacrolimus (n = 4), rituximab (n = 3), cyclophosphamide (n = 1), tocilizumab (n = 1), and mycophenolate mofetil (n = 1) (Table 4). Eleven of these patients had favorable responses. One patient (case #3) did not improve after 10 months of immunotherapy, and in one case (#9), the effect of immunotherapy could not be assessed because the patient was lost to follow-up. In three patients, symptoms improved after treatment with rituximab but not after treatment with IVIG or corticosteroids. In the first patient (case #5), cognitive impairment improved gradually with IVIG, but gait disturbance remained. This gait disturbance improved significantly after treatment with rituximab. In the second patient (case #10), ataxia and
Table 1 Demographics and clinical characteristics of the patients. Patient Sex Age Presenting symptoms
LE BE Cerebellar dysfunction
1 2 3 4 5
M F F M M
73 74 73 66 65
+
6 7 8 9
M M F M
63 84 59 75
10 11
F M
71 42
12 13 14
M F F
39 28 30
15 16 17
M F M
31 44 63
Seizure, irritability, vertigo, left 6th nerve palsy, right 8th nerve palsy Vertigo, nystagmus, orthostatic hypotension Sensory polyneuropathy Cognitive impairment (K-MMSE 22) Cognitive impairment (K-MMSE 20), irritability, dizziness, ataxia, orthostatic hypotension, sensory polyneuropathy Delayed gastric emptying General weakness, sensorimotor polyneuropathy Cognitive impairment (K-MMSE 17), orthostatic hypotension Ophthalmoplegia, hoarseness, dysphagia, ataxia, postural instability, orthostatic hypotension (C3 myelitis on MRI) Postural instability, dysmetria, orthostatic hypotension Altered mentality, bilateral 6th nerve palsy, GEN, dysarthria, right leg weakness, Babinski sign, dysmetria Cognitive impairment (K-MMSE 29), irritability, postural instability POTS Dysarthria, right side weakness, right hand dystonia, right homonymous hemianopsia Seizure, confusion (bilateral hippocampal atrophy on MRI) Seizure, cognitive impairment (K-MMSE 17), psychosis (schizophrenia) Sensorimotor polyneuropathy
18 19 20
F M M
68 62 41
Cognitive impairment (K-MMSE 22), irritability Dizziness, postural instability Dizziness, GEN, ataxia, postural instability, POTS
Myelitis PN Dysautonomia Other clinical considerations
+ +
+ +
+ +
+
+
+ +
+ + +
+ +
+ +
+
+
+
+
DM DM
CSF EBV PCR(+) + +
Ovarian cyst
+ + +
+ +
MND + sensorimotor neuropathy
+ +
+ +
+
CSF EBV PCR(+)
LE: limbic encephalitis, BE: brainstem encephalitis, PN: polyneuropathy, M: male, F: female, K-MMSE: Korean version of minimental status examination, GEN: gaze evoked nystagmus, POTS: postural orthostatic tachycardia syndrome, DM: diabetes mellitus, CSF: cerebrospinal fluid, EBV: Epstein–barr virus, PCR: polymerase chain reaction, MND: motor neuron disease.
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Table 2 Coexisting antibodies, type of the cancer, time course of the symptoms and ancillary tests. Patient Cancer
Cancer Cancer to screening neurological symptom time (mo)
Neurological symptom without cancer (mo)
Brain MRI
CSF study
NCS
Coexisting antibodiesa
Linear T2 HSI lesion along interpeduncular, ambient and quadrigeminal cistern, both cerebellopontine angle and adjacent 4th ventricle
(−)
None (CSF)
(−)
None (serum) Yo positive (serum) None (CSF) None (serum)
1
NSCLC
2
Cervical
6
Normal
WBC 34/ μL Protein 12 mg/ dL (−)
3
Ovarian
2
Normal
(−)
Sensory PN
4
SCLC
12
Normal
Sensory PN
5
EGC
18
Normal
6
Esophageal
Normal
WBC 14/ μL Protein 52 mg/ dL (−)
7
AGC
2
Normal
(−)
sensorimotor PN
8
Not found
75
Normal
(−)
(−)
9
Not found
48
Normal
None (serum)
Not found
Normal Spine MRI: T2 HSI lesion with enhancement in the upper cervical spinal cord (C1–C4) Normal
Normal
10
Normal
(−)
None (serum)
11
Not found
Chest & abdomen CT Chest & abdomen CT Whole body FDG-PET Whole body FDG-PET
Diffuse leptomeningeal enhancement with T2 HSI in both basal ganglia and thalami
(−)
None (CSF)
12
Not found
44
Communicating hydrocephalus
(−)
None (serum)
13
Not found
Brain CT: normal
(−)
(−)
None (serum)
14
Not found
T2 HSI lesion in right frontal lobe and left insula, frontal, tempo-occipital lobe
Noneb (serum)
Not found
Normal
Protein 134 mg/ dL (−)
Normal
15
(−)
None (serum)
16
Not found
Bilateral hippocampal sclerosis
Normal
(−)
Ri positive (serum)
17
Not found
24
Normal
Normal
Sensorimotor Noneb PN + MND (serum)
18
Not found
30
Normal
Normal
(−)
None (serum)
19
Not found
Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Not done
WBC 311/μL Protein 210 mg/ dL Normal
12
Diffuse cerebellar atrophy and brainstem atrophy
(−)
(−)
20
Not found
30
Multifocal subtle leptomeningeal enhancement
WBC 46/ μL (L41, O5)
Normal
None (serum) NMDAR positive (serum)
11
3
Chest & abdomen CT
32
4
6
20
6
132
Normal
(−)
Noneb (serum) Hu positiveb (serum) None (serum)
Mo: month, MRI: magnetic resonance image, CSF: cerebrospinal fluid, NCS: nerve conduction study, NSCLC: non-small cell lung cancer, SCLC: small cell lung cancer, EGC: early gastric cancer, AGC: advanced gastric cancer, CT: computed tomography, FDG-PET: fluoro-deoxyglucose positron emission tomography, HSI: high signal intensity, WBC: white blood cell. a: Amphiphysin antibody was detected in the serum. Antibody testing for Hu, Yo, Ri, Ma2, CV2/CRMP, NMDAR1, AMPAR1, AMPAR2, GABAB-R, LGI1, and CASPR2 was performed. b: Antibody testing only for Hu, Yo, Ri, Ma2 and CV2/CRMP was performed.
postural instability were not improved by treatment with IVIG and steroid pulse therapy, but they improved following treatment with rituximab. The third patient (case #20) persistently suffered from ataxia and postural instability for nearly 1 year after IVIG treatment, but the symptoms improved after treatment with rituximab. Due to the high cost of rituximab, other immunosuppressive agents such as tacrolimus,
tocilizumab, and mycophenolate mofetil were given to the patients following rituximab. In some patients, mycophenolate mofetil or tacrolimus was more effective than rituximab at improving symptoms. Mycophenolate mofetil was given more than six months after rituximab treatment in one patient (case #10), and tacrolimus was prescribed when the patient's symptoms were aggravated after short-term effect
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Table 3 Characteristics of patients with cancer and without cancer.
Patients (n, %) Mean age Sex (M:F) Time between diagnosis of cancer and development of neurological symptoms (mean, range; mo) Time with neurological symptoms but no cancer (mean, range; mo) Immunotherapy (n, %)
With cancer
Without cancer
7 (35%) 71.1 5:2 5.5 (2–11)a –
13 (65%) 50.2 7:6 –
4 (57.1%)
32.2 (2–132) 9 (69.2%)
M: male, F: female, mo: month. a n = 4.
of rituximab in other patient (case #20), which both resulted in significant improvement of the patients' conditions. Modified Rankin Scale (mRS) was assessed in 12 patients before and after the immunotherapy. After treatment, mRS decreased in eight patients, 11 were able to walk unassisted, and one (case #1) died due to an unrelated complication (Table 4, Fig. 1).
4. Discussion This study showed that many patients with amphiphysin autoimmunity develop neurological symptoms instead of SPS and that many of the cases are not associated with cancer. Most of these neurological symptoms improved after immune-modulating therapy. Autoimmune neurological disorder due to amphiphysin antibody should be considered as a potential differential diagnosis in patients who have subacute onset of neurological symptoms without any other cause. When amphiphysin antibody is identified, patients should have an extensive workup to detect cancer even though cancer will not be present in most cases. Immunotherapy should be attempted irrespective of the amount of time since symptom onset. Second-line immunotherapy must be considered when first-line treatment (steroids or IVIG) fails.
Fig. 1. Clinical outcome in patients who underwent immunotherapy. Changes in modified Rankin Score (mRS) before and after the treatment (Tx) are shown in individual patients who underwent immunotherapy (n = 12). The thickness of the line is proportional to the number of the patients who displayed identical change in mRS.
As in a previous report, we found that many patients with amphiphysin autoimmunity have neurological symptoms other than SPS. To date, only one large case series (n = 63) of patients with amphiphysin autoimmunity has been reported. It found the following neurological manifestations of amphiphysin autoimmunity (in order of decreasing frequency): neuropathy (n = 33; 52.4%), encephalopathy (n = 19; 30.2%), SPS (n = 18; 28.6%), myelopathy (n = 17; 27.0%), and cerebellar syndrome (n = 11; 17.5%) (Pittock et al., 2005). The current study also showed that the patients with amphiphysin autoimmunity had a variety of neurological manifestations: limbic encephalitis was the most common neurological symptom (n = 10; 50%). Dysautonomia (n = 9; 45%) and cerebellar dysfunction (n = 6; 30%) were more common than in the previous case series. We designated patients with these neurological symptoms other than SPS as having NSAS. Dysautonomia has not been widely reported in patients with amphiphysin autoimmunity. Although we still do not know the exact
Table 4 Effect of immunotherapy in patients. Patient Immunotherapy (in sequential order)
FU term after treatment (month)
Treatment effect
1 2 3 4 5
IVIG + MPd Not done IVIG + MPd, oral Pd Not done IVIG, rituximab, tacrolimus
0
Decreased seizure, but died due to pulmonary embolism (mRS 4 → 6)
10
Not significant (mRS 2 → 2)
17
Improvement of cognitive impairment (K-MMSE 20 → 25, gradual improvement), gait disturbance (after rituximab) (mRS 4 → 3)
6 7 8 9 10
Not done IVIG + oral Pd IVIG Tacrolimus IVIG + MPd, rituximab, tacrolimus, tocilizumab, mycophenolate mofetil IVIG, oral Pd
8 10 FU loss 14
Improvement of general weakness (assisted gait → self walker-gait) (mRS 4 → 3) Improvement of cognitive impairment (K-MMSE 17 → 22) (mRS 2 → 1)
12 18
Improvement of dysarthria, weakness, and right hand dystonia (mRS 3 → 2)
15 16 17 18
IVIG + MPd Not done IV dexamethasone, IVIG, oral Pd, cyclophosphamide Not done IVIG + MPd Not done IVIG + oral Pd
Improvement of ataxia and postural instability (after rituximab, mycophenolate mofetil) (mRS 4 → 3) Improvement of altered mentality and cranial nerve palsy (significantly after ganciclovir) (mRS 3 → 1) Improvement of dizziness, ataxia (mRS 2 → 1)
13
Improvement of depression, emotional lability, and psychotic symptom (mRS 2 → 2)
5
Improvement of subjective cognitive impairment and irritability (K-MMSE not checked) (mRS 2 → 2)
19 20
Not done IVIG, rituximab, tacrolimus
FU loss 23 (IVIG), 14 (rituximab), 10 (tacrolimus)
11 12 13 14
4
Improvement of ataxia and postural instability (after rituximab, tacrolimus) (mRS 3 → 2)
FU: follow up, IVIG: intravenous immunoglobulin, MPd: intravenous methylprednisolone pulse therapy, Pd: prednisolone, IVIG + MPd: combination therapy, mRS: modified Rankin Scale.
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mechanism of dysautonomia, we think that it is a manifestation of autonomic neuropathy which may be developed by a similar mechanism to that of sensorimotor polyneuropathy. It is also noticeable that neuropathy, which was found in more than half of the patients in the previous report (Pittock et al., 2005), was present in only one-fifth of our patients despite detailed neurological examinations and sufficient diagnostic tests. Reduced presynaptic GABAergic inhibition is believed to be the main pathologic effect of amphiphysin autoimmunity (Geis et al., 2010). The variety of neurological manifestations in patients with amphiphysin autoimmunity may be explained by the widespread distribution of amphiphysin protein and GABAergic neurons. Because amphiphysin is an intracellular synaptic antigen, the epitope is exposed to antibodies during synaptic vesicle fusion and reuptake (Lancaster and Dalmau, 2012). Disrupting amphiphysin function impairs synaptic vesicle endocytosis and reduces the releasable vesicle pool, predominantly in GABAergic neurons. This reduces the GABAergic inhibition and may cause various neurological symptoms (Geis et al., 2010). Amphiphysin autoimmunity seems to be due to both cellular and humoral immune responses (Lancaster and Dalmau, 2012). A few postmortem studies have demonstrated infiltration of cytotoxic T cells in the brain, spinal cord and dorsal root ganglia of patients with amphiphysin autoimmunity (Pittock et al., 2005; Holmøy et al., 2009). In addition, passive transfer of amphiphysin IgG antibody resulted in stiffness, muscle spasm, and behavioral changes in animals (Sommer et al., 2005; Geis et al., 2010, 2012), suggesting that the antibody is pathogenic. According to the previous report, cancer was detected in 79% of patients with amphiphysin autoimmunity (Pittock et al., 2005). In contrast, in our study, underlying cancer was detected in only about one-third of the patients (7/20; 35%); the remainder had neurological symptoms without cancer. Although breast and small cell lung cancer are the most common malignancies associated with anti-amphiphysin syndromes (Pittock et al., 2005), we only detected one case of small cell lung cancer, and instead mostly detected other types of cancer. Accordingly, NSAS, as presented here, might be a non-paraneoplastic manifestation of amphiphysin autoimmunity. A considerable fraction of the patients (8/20; 40%) had neurological symptoms without cancer for more than 2 years. In particular, in case #16, cancer was not detected until 11 years after the onset of neurological symptoms despite extensive screening. It is appreciable that most of the patients (16/20; 80%) developed neurologic syndromes before cancer was detected. Of these, only three (18.8%, cases #4, #5, and #7) were diagnosed with cancer after the antibody was detected. This implies that neurological symptoms caused by amphiphysin antibody can occur without cancer and therefore suspicion of anti-amphiphysin syndrome is important. Many patients with amphiphysin antibody have coexisting autoantibodies (Pittock et al., 2004, 2005). In patients with multiple autoantibodies, determining which antibodies are responsible for clinical syndromes is difficult. Amphiphysin antibody, however, can be present in the absence of other autoantibodies. In our study, only four patients (20%) had coexisting autoantibodies, which is fewer than previously reported (74%) (Pittock et al., 2005). Despite a comprehensive investigation for 12 paraneoplastic antibodies, no other autoantibodies were identified in most of the patients (16/20; 80%), indicating that amphiphysin antibody may be the only evidence for a paraneoplastic neurological syndrome and alone may lead to the identification of an occult neoplasm. In case #4, for example, lung cancer was detected during the diagnostic evaluation of isolated amphiphysin autoimmunity. Our results suggest that neurological syndromes caused by amphiphysin autoimmunity are reversible and that immunotherapy might be helpful even at a late stage. Favorable responses to immunotherapy have been reported in a few cases of SPS associated with amphiphysin autoimmunity (Murinson and Guarnaccia, 2008; Dupond et al., 2010), but the efficacy of immunotherapy in NSAS has not yet been established. A single report of patients with paraneoplastic
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neurological syndromes related to amphiphysin autoimmunity showed neurological improvements in four of five treated with methylprednisolone and two of five treated with IVIG, but which symptoms improved was not described (Pittock et al., 2005). The current report is the first to describe the efficacy of immunotherapy in patients with NSAS. Most of the patients who received immunotherapy (11/13; 84.6%) had favorable responses irrespective of the time since the onset of symptoms. Excluding one patient (case #9) who was lost to follow-up, only one patient (case #3) was not responsive to immunotherapy. On the other hand, remarkably, one patient (case #16) responded to immunotherapy even though treatment was started 10 years after the symptom onset. IVIG and steroids are the most widely used agents for first-line immunotherapy in paraneoplastic neurological syndromes (Viaccoz, 2013). Recently, some studies have shown that second-line immunotherapy (rituximab, cyclophosphamide) is usually effective in antiNMDA receptor encephalitis (Titulaer et al., 2013; Lim et al., 2014). In our study, IVIG and steroids (methylprednisolone or prednisolone) were the most commonly used immunotherapy agents, and most patients had favorable responses to them. However, in some patients, the neurological symptom did not respond to IVIG or steroids and only improved after additional treatment with rituximab (cases #5, #10 and #20). Rituximab is a chimeric monoclonal antibody against protein CD20 and destroys B cells, and therefore is used to treat various autoimmune disorders caused by dysfunctional B cells (Vincent et al., 2011). Only one previous report has documented the effectiveness of rituximab in a patient with amphiphysin-related SPS (Dupond et al., 2010). Here, we describe three patients who were successfully treated with rituximab. Our data suggest that rituximab may be a good choice for second-line immunotherapy in patients with amphiphysin autoimmunity. Interestingly, the therapeutic effect of mycophenolate mofetil or tacrolimus was even better than rituximab in some cases (cases #10 and #20, respectively). Delayed effect of rituximab is unlikely in these cases because of the substantial time gap between two treatments and subsequent aggravation after transient rituximab effect. As mentioned above, the pathogenesis of anti-amphiphysin syndrome is thought to be influenced by both cellular and humoral immunities. Rituximab suppresses B cell function, tacrolimus suppresses T cell function, and mycophenolate mofetil suppresses both. Although individual response differs between these agents, responsiveness to these provides additional support for the involvement of both cellular and humoral immunities in NSAS. Secondary autoimmune disease can occur after viral infection of the central nervous system by herpes simplex virus or Epstein–Barr virus (Pender, 2003; Barzilai et al., 2007; Prüss et al., 2012; Lim et al., 2013; DeSena et al., 2014). Following herpes simplex virus encephalitis, patients frequently have anti-NMDA receptor antibodies (Prüss et al., 2012; DeSena et al., 2014). In our study, amphiphysin antibodies were detected after Epstein–Barr virus encephalitis in two patients. Symptoms in both patients continuously improved in response to immunotherapy following antiviral treatment. We therefore recommend that immune-modulating therapy should be used to control secondary autoimmune processes, including amphiphysin autoimmunity, triggered by viral encephalitis. One limitation of our study is that we have used the immunoblotting method to detect amphiphysin antibody, which is different from the method used by the previous case series study (Pittock et al., 2005). Pittock et al. screened the antibody by using sections of various rodent tissues at first, and then used immunoblotting by using rodent brain extracts and recombinant proteins to confirm the result. The two different approaches might have led to the different patient populations in each study. Our study suggests that anti-amphiphysin syndrome can manifest as non-stiff encephalomyelitis and that it is only partially associated with cancer. Cellular and humoral immunities both appear to play important roles in the pathogenesis of NSAS. Immune-modulating therapies
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including rituximab may be a good choice for the treatment of this disease. A large scale well-designed study is needed to examine the long-term efficacy of immunotherapy in the treatment of NSAS. Author contribution Dr. Jangsup Moon, Soon-Tae Lee, and Kon Chu — study Concept and design. Dr. Jangsup Moon, Keon-Joo Lee, Soon-Tae Lee, and Kon Chu — acquisition of data. Dr. Jangsup Moon, Yong-Won Shin, and Tae-Joon Kim — analysis and interpretation. Dr. Jung-Won Shin, Jung-Ick Byun, Jung-Ah Lim, Kyung-Il Park, Keun-Hwa Jung, and Ki-Young Jung — critical revision of the manuscript for important intellectual content. Dr. Kon Chu and Sang Kun Lee — study supervision. Acknowledgments This study was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (HI11C1347). S.K.L. was supported by Seoul National University Hospital Research Funds (0420130580). References Antoine, J.C., Absi, L., Honnorat, J., Boulesteix, J.-M., de Brouker, T., Vial, C., et al., 1999. Antiamphiphysin antibodies are associated with various paraneoplastic neurological syndromes and tumors. Arch. Neurol. 56, 172. Barzilai, O., Sherer, Y., Ram, M., Izhaky, D., Anaya, J., Shoenfeld, Y., 2007. Epstein–Barr virus and cytomegalovirus in autoimmune diseases. Ann. N. Y. Acad. Sci. 1108, 567–577. Chamard, L., Magnin, E., Berger, E., Hagenkötter, B., Rumbach, L., Bataillard, M., 2011. Stiff leg syndrome and myelitis with anti-amphiphysin antibodies: a common physiopathology? Eur. Neurol. 66, 253–255. Coppens, T., Van den Bergh, P., Duprez, T., Jeanjean, A., De Ridder, F., Sindic, C., 2006. Paraneoplastic rhombencephalitis and brachial plexopathy in two cases of amphiphysin auto-immunity. Eur. Neurol. 55, 80–83. De Camilli, P., Thomas, A., Cofiell, R., Folli, F.,Lichte, B., Piccolo, G., et al., 1993. The synaptic vesicle-associated protein amphiphysin is the 128-kD autoantigen of Stiff-Man syndrome with breast cancer. J. Exp. Med. 178, 2219–2223. DeSena, A.,Graves, D.,Warnack, W.,Greenberg, B.M., 2014. Herpes simplex encephalitis as a potential cause of anti-N-methyl-D-aspartate receptor antibody encephalitis: report of 2 cases. JAMA Neurol. 71, 344–346. Dorresteijn, L.D., Kappelle, A.C., Renier, W.O., Gijtenbeck, J.M., 2002. Anti-amphiphysin associated limbic encephalitis: a paraneoplastic presentation of small-cell lung carcinoma. J. Neurol. 249, 1307–1308.
Dupond, J.,Essalmi, L.,Gil, H.,Meaux-Ruault, N.,Hafsaoui, C., 2010. Rituximab treatment of stiff-person syndrome in a patient with thymoma, diabetes mellitus and autoimmune thyroiditis. J. Clin. Neurosci. 17, 389–391. Flanagan, E., McKeon, A., Lennon, V., Kearns, J., Weinshenker, B., Krecke, K., et al., 2011. Paraneoplastic isolated myelopathy: clinical course and neuroimaging clues. Neurology 76, 2089–2095. Geis, C., Weishaupt, A., Hallermann, S., Grünewald, B., Wessig, C., Wultsch, T., et al., 2010. Stiff person syndrome-associated autoantibodies to amphiphysin mediate reduced GABAergic inhibition. Brain 133, 3166–3180. Geis, C., Grünewald, B., Weishaupt, A., Wultsch, T., Toyka, K.V., Reif, A., et al., 2012. Human IgG directed against amphiphysin induces anxiety behavior in a rat model after intrathecal passive transfer. J. Neural Transm. 119, 981–985. Holmøy, T., Skorstad, G., Røste, L.S., Scheie, D., Alvik, K., 2009. Stiff person syndrome associated with lower motor neuron disease and infiltration of cytotoxic T cells in the spinal cord. Clin. Neurol. Neurosurg. 111, 708–712. Krishna, V., Knievel, K., Ladha, S., Sivakumar, K., 2012. Lower extremity predominant stiff-person syndrome and limbic encephalitis with amphiphysin antibodies in breast cancer. J. Clin. Neuromuscul. Dis. 14, 72. Lancaster, E.,Dalmau, J., 2012. Neuronal autoantigens—pathogenesis, associated disorders and antibody testing. Nat. Rev. Neurol. 8, 380–390. Lichte, B., Veh, R.W., Meyer, H.E., Kilimann, M.W., 1992. Amphiphysin, a novel protein associated with synaptic vesicles. EMBO J. 11, 2521. Lim, J.A., Byun, J.I., Lee, S.T., Jung, K.H., Kim, Y.S., Kim, J.M., et al., 2013. Epstein–Barr virus brainstem encephalitis with anti-N-methyl-D-aspartate receptor antibodies. J. Korean Neurol. Assoc. 31, 199–202. Lim, J.-A., Lee, S.-T., Jung, K.-H., Kim, S., Shin, J.-W., Moon, J., et al., 2014. Anti-N-methyl-Daspartate receptor encephalitis in Korea: clinical features, treatment, and outcome. J. Clin. Neurol. 10, 157–161. Murinson, B.B.,Guarnaccia, J.B., 2008. Stiff-person syndrome with amphiphysin antibodies: distinctive features of a rare disease. Neurology 71, 1955–1958. Pender, M.P., 2003. Infection of autoreactive B lymphocytes with EBV, causing chronic autoimmune diseases. Trends Immunol. 24, 584–588. Perego, L., Previtali, S., Nemni, R., Longhi, R., Carandente, O., Saibene, A., et al., 2002. Autoantibodies to amphiphysin I and amphiphysin II in a patient with sensory-motor neuropathy. Eur. Neurol. 47, 196–200. Pittock, S.J., Kryzer, T.J., Lennon, V.A., 2004. Paraneoplastic antibodies coexist and predict cancer, not neurological syndrome. Ann. Neurol. 56, 715–719. Pittock, S.J., Lucchinetti, C.F., Parisi, J.E., Benarroch, E.E., Mokri, B., Stephan, C.L., et al., 2005. Amphiphysin autoimmunity: paraneoplastic accompaniments. Ann. Neurol. 58, 96–107. Prüss, H.,Finke, C.,Höltje, M.,Hofmann, J.,Klingbeil, C.,Probst, C., et al., 2012. N‐methyl‐D‐aspartate receptor antibodies in herpes simplex encephalitis. Ann. Neurol. 72, 902–911. Shin, Y.-W.,Lee, S.-T.,Shin, J.-W.,Moon, J., Lim, J.-A.,Byun, J.-I., et al., 2013. VGKC-complex/ LGI1-antibody encephalitis: clinical manifestations and response to immunotherapy. J. Neuroimmunol. 265, 75–81. Sommer, C., Weishaupt, A., Brinkhoff, J., Biko, L., Wessig, C., Gold, R., et al., 2005. Paraneoplastic stiff-person syndrome: passive transfer to rats by means of IgG antibodies to amphiphysin. Lancet 365, 1406–1411. Titulaer, M.J., McCracken, L., Gabilondo, I., Armangué, T., Glaser, C., Iizuka, T., et al., 2013. Treatment and prognostic factors for long-term outcome in patients with antiNMDA receptor encephalitis: an observational cohort study. Lancet Neurol. 12, 157–165. Viaccoz, A., 2013. Paraneoplastic neurological syndromes: general treatment overview. Current Treatment Options in Neurologypp. 1–19. Vincent, A., Bien, C.G., Irani, S.R.,Waters, P., 2011. Autoantibodies associated with diseases of the CNS: new developments and future challenges. Lancet Neurol. 10, 759–772.
Contents lists available at ScienceDirect
Journal of Neuroimmunology journal homepage: www.elsevier.com/locate/jneuroim
Non-stiff anti-amphiphysin syndrome: Clinical manifestations and outcome after immunotherapy Jangsup Moon a,b,1, Soon-Tae Lee a,b,1, Jung-Won Shin a,b, Jung-Ick Byun a,b, Jung-Ah Lim a,b, Yong-Won Shin a,b, Tae-Joon Kim a,b, Keon-Joo Lee a,b, Kyung-Il Park c, Keun-Hwa Jung a,b, Ki-Young Jung a,b, Sang Kun Lee a,b, Kon Chu a,b,⁎ a b c
Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Department of Neurology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, South Korea
a r t i c l e
i n f o
Article history: Received 15 May 2014 Received in revised form 13 July 2014 Accepted 16 July 2014 Keywords: Anti-amphiphysin antibody Paraneoplastic neurological syndrome Stiff-person syndrome Immunotherapy rituximab
a b s t r a c t Amphiphysin antibody causes paraneoplastic stiff-person syndrome and can also result in a variety of neurological manifestations. Here, we investigated the clinical spectrum of 20 patients with non-stiff anti-amphiphysin syndrome and their responses to immunotherapy. The most common neurological manifestation was limbic encephalitis (n = 10), followed by dysautonomia (n = 9), and cerebellar dysfunction (n = 6). Cancer was detected in only seven patients. Intravenous immunoglobulin or steroid treatment was effective in most patients, but three improved only after rituximab treatment. Our study suggests that anti-amphiphysin syndrome can manifest as non-stiff encephalomyelitis and is only partially associated with cancer. Active immunotherapy, including rituximab, would be beneficial. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Amphiphysin is an intracellular synaptic vesicle protein discovered in 1992 (Lichte et al., 1992) that is involved in retrieving vesicle membranes from the axon terminal's plasma membrane after exocytosis of neurotransmitters (Coppens et al., 2006). Amphiphysin antibody was initially described in patients with paraneoplastic stiff-person syndrome (SPS) (De Camilli et al., 1993), but it was later found in many other types of paraneoplastic neurological syndromes (Pittock et al., 2005). Several case reports and small case series have demonstrated that amphiphysin autoimmunity is associated with limbic encephalitis (Dorresteijn et al., 2002; Krishna et al., 2012), brainstem encephalitis (Coppens et al., 2006), myelopathy (Chamard et al., 2011; Flanagan et al., 2011), peripheral neuropathy (Antoine et al., 1999; Perego et al., 2002; Coppens et al., 2006) and cerebellar dysfunction (Coppens et al., 2006). In 2005, Pittock and colleagues reported SPS in 18 of 63 patients
⁎ Corresponding author at: Department of Neurology, Seoul National University Hospital, 101 Daehang-no, Chongro-gu, Seoul 110-744, South Korea. Tel.: +82 2 2072 1878; fax: +82 2 2072 7424. E-mail address: [email protected] (K. Chu). 1 The first two authors contributed equally to this work.
http://dx.doi.org/10.1016/j.jneuroim.2014.07.011 0165-5728/© 2014 Elsevier B.V. All rights reserved.
(28.6%) with amphiphysin autoimmunity, most of whom had non-stiff encephalomyelitis (Pittock et al., 2005). In addition, according to the report, about 80% of the patients had cancer and about three-fourths had coexisting paraneoplastic antibodies. To date, only a few reports have shown favorable effects of immunotherapy in amphiphysin-related SPS (Murinson and Guarnaccia, 2008; Dupond et al., 2010). Data on the effect of immunotherapy in non-stiff anti-amphiphysin syndrome (NSAS), however, are very limited. In this study, we describe the clinical features in 20 NSAS patients caused by amphiphysin autoimmunity and the outcome of treatment with immunotherapy. 2. Methods This study was conducted at Seoul National University Hospital, a tertiary referral hospital, and was approved by its institutional review board. Between October 2012 and March 2014, patients with possible paraneoplastic syndrome (limbic encephalitis, brainstem encephalitis, cerebellar ataxia, dysautonomia, or polyneuropathy of unknown etiology) were screened for classical paraneoplastic (nuclear or cytoplasmic) or autoimmune synaptic antibodies. Amphiphysin antibody was detected by immunoblotting. Briefly, diluted patient's serum (1:10 to 1:100) or cerebrospinal fluid (1:10) was incubated with recombinant amphiphysin protein and detected by anti-human IgG using an immunoblotting kit (Euroimmun AG,
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Lübeck, Germany). Samples were also tested for the following classical paraneoplastic antibodies and autoimmune synaptic antibodies using detection kits (Euroimmun): anti-Hu, anti-Yo, anti-Ri, anti-Ma2, anti-CV2/CRMP, anti-NMDA receptor, anti-LGI1, anti-Caspr2, antiAMPA1 receptor, anti-AMPA2 receptor, and anti-GABA-b receptor (Shin et al., 2013). Patients who were positive for amphiphysin antibody were included in the analysis. For each patient, the following information was recorded: clinical features, laboratory findings, cerebrospinal fluid profile, electroencephalogram, brain magnetic resonance imaging, nerve conduction study and electromyogram, fluoro-deoxyglucose positron emission tomography, and other radiologic screening tests for detecting systemic neoplasm. 3. Results 3.1. Clinical features of anti-amphiphysin syndrome Between October 2012 and March 2014, amphiphysin antibody was identified in the serum of 20 patients (12 men, eight women; mean age, 57.6 ± 17.2 years). Ten patients were diagnosed with limbic encephalitis, nine with dysautonomia, six with cerebellar dysfunction, and four with brainstem encephalitis. Four patients had peripheral neuropathy and one had myelitis (Table 1). Brain MRI was performed in every patients, which revealed parenchymal T2 high signal intensity (HSI) lesions in three patients and leptomeningeal enhancement in two patients. One patient had T2 HSI lesion in upper cervical spinal cord. CSF pleocytosis was present in four patients. Four patients showed polyneuropathy in nerve conduction studies (Table 2). Cancer was detected in seven patients (35%), which included nonsmall cell lung cancer (n = 1), small cell lung cancer (n = 1), ovarian cancer (n = 1), cervical cancer (n = 1), esophageal cancer (n = 1), and gastric cancer (n = 2). To check for hidden malignancies in rest of the patients, chest and abdomen computed tomography or whole body fluoro-deoxyglucose positron emission tomography was performed in all but one patient (case #19), but no additional cancer was detected (Table 2). Patients with cancer were, on average, older than patients without cancer (mean = 71.1 vs. 50.2 years) (Table 3).
Among the seven patients diagnosed with cancer, four developed neurological symptoms after (mean time, 5.5 months [range, 2–11]) and three before the diagnosis of cancer. In two cases (cases #4 and #7), cancer was detected during the diagnostic workup for the patient's neurological symptoms. In another (case #5), gait disturbance and orthostatic dizziness were detected 1.5 years before the diagnosis of cancer, and psychotic symptoms appeared 1 month after its detection. In the 13 patients without cancer, neurological symptoms lasted for an average of 32.2 months (range, 2–132). Interestingly, one patient (case #16) had been treated by a psychiatric department for 10 years for psychotic symptoms before amphiphysin antibody was detected. In two patients, amphiphysin antibodies were detected after prior history of Epstein–Barr virus encephalitis (Table 1). One patient (case #11) initially experienced fever followed by progressive dizziness, dysarthria, spasticity of one leg, and confusion. The other patient (case #20) first complained of progressive headache and dizziness, and later developed brainstem dysfunction and ataxia. In both patients, EBV infections were confirmed by viral PCR of CSF samples and amphiphysin antibodies were revealed more than one month after the onset of initial symptoms. Additional autoantibodies (Hu, Yo, Ri, and NMDA antibodies) were detected in four patients (cases #3, #7, #16 and #20) (Table 2). 3.2. Effect of treatment Thirteen patients were treated with immunotherapy, which included intravenous immunoglobulin (IVIG) (n = 12), corticosteroids (n = 9), tacrolimus (n = 4), rituximab (n = 3), cyclophosphamide (n = 1), tocilizumab (n = 1), and mycophenolate mofetil (n = 1) (Table 4). Eleven of these patients had favorable responses. One patient (case #3) did not improve after 10 months of immunotherapy, and in one case (#9), the effect of immunotherapy could not be assessed because the patient was lost to follow-up. In three patients, symptoms improved after treatment with rituximab but not after treatment with IVIG or corticosteroids. In the first patient (case #5), cognitive impairment improved gradually with IVIG, but gait disturbance remained. This gait disturbance improved significantly after treatment with rituximab. In the second patient (case #10), ataxia and
Table 1 Demographics and clinical characteristics of the patients. Patient Sex Age Presenting symptoms
LE BE Cerebellar dysfunction
1 2 3 4 5
M F F M M
73 74 73 66 65
+
6 7 8 9
M M F M
63 84 59 75
10 11
F M
71 42
12 13 14
M F F
39 28 30
15 16 17
M F M
31 44 63
Seizure, irritability, vertigo, left 6th nerve palsy, right 8th nerve palsy Vertigo, nystagmus, orthostatic hypotension Sensory polyneuropathy Cognitive impairment (K-MMSE 22) Cognitive impairment (K-MMSE 20), irritability, dizziness, ataxia, orthostatic hypotension, sensory polyneuropathy Delayed gastric emptying General weakness, sensorimotor polyneuropathy Cognitive impairment (K-MMSE 17), orthostatic hypotension Ophthalmoplegia, hoarseness, dysphagia, ataxia, postural instability, orthostatic hypotension (C3 myelitis on MRI) Postural instability, dysmetria, orthostatic hypotension Altered mentality, bilateral 6th nerve palsy, GEN, dysarthria, right leg weakness, Babinski sign, dysmetria Cognitive impairment (K-MMSE 29), irritability, postural instability POTS Dysarthria, right side weakness, right hand dystonia, right homonymous hemianopsia Seizure, confusion (bilateral hippocampal atrophy on MRI) Seizure, cognitive impairment (K-MMSE 17), psychosis (schizophrenia) Sensorimotor polyneuropathy
18 19 20
F M M
68 62 41
Cognitive impairment (K-MMSE 22), irritability Dizziness, postural instability Dizziness, GEN, ataxia, postural instability, POTS
Myelitis PN Dysautonomia Other clinical considerations
+ +
+ +
+ +
+
+
+ +
+ + +
+ +
+ +
+
+
+
+
DM DM
CSF EBV PCR(+) + +
Ovarian cyst
+ + +
+ +
MND + sensorimotor neuropathy
+ +
+ +
+
CSF EBV PCR(+)
LE: limbic encephalitis, BE: brainstem encephalitis, PN: polyneuropathy, M: male, F: female, K-MMSE: Korean version of minimental status examination, GEN: gaze evoked nystagmus, POTS: postural orthostatic tachycardia syndrome, DM: diabetes mellitus, CSF: cerebrospinal fluid, EBV: Epstein–barr virus, PCR: polymerase chain reaction, MND: motor neuron disease.
J. Moon et al. / Journal of Neuroimmunology 274 (2014) 209–214
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Table 2 Coexisting antibodies, type of the cancer, time course of the symptoms and ancillary tests. Patient Cancer
Cancer Cancer to screening neurological symptom time (mo)
Neurological symptom without cancer (mo)
Brain MRI
CSF study
NCS
Coexisting antibodiesa
Linear T2 HSI lesion along interpeduncular, ambient and quadrigeminal cistern, both cerebellopontine angle and adjacent 4th ventricle
(−)
None (CSF)
(−)
None (serum) Yo positive (serum) None (CSF) None (serum)
1
NSCLC
2
Cervical
6
Normal
WBC 34/ μL Protein 12 mg/ dL (−)
3
Ovarian
2
Normal
(−)
Sensory PN
4
SCLC
12
Normal
Sensory PN
5
EGC
18
Normal
6
Esophageal
Normal
WBC 14/ μL Protein 52 mg/ dL (−)
7
AGC
2
Normal
(−)
sensorimotor PN
8
Not found
75
Normal
(−)
(−)
9
Not found
48
Normal
None (serum)
Not found
Normal Spine MRI: T2 HSI lesion with enhancement in the upper cervical spinal cord (C1–C4) Normal
Normal
10
Normal
(−)
None (serum)
11
Not found
Chest & abdomen CT Chest & abdomen CT Whole body FDG-PET Whole body FDG-PET
Diffuse leptomeningeal enhancement with T2 HSI in both basal ganglia and thalami
(−)
None (CSF)
12
Not found
44
Communicating hydrocephalus
(−)
None (serum)
13
Not found
Brain CT: normal
(−)
(−)
None (serum)
14
Not found
T2 HSI lesion in right frontal lobe and left insula, frontal, tempo-occipital lobe
Noneb (serum)
Not found
Normal
Protein 134 mg/ dL (−)
Normal
15
(−)
None (serum)
16
Not found
Bilateral hippocampal sclerosis
Normal
(−)
Ri positive (serum)
17
Not found
24
Normal
Normal
Sensorimotor Noneb PN + MND (serum)
18
Not found
30
Normal
Normal
(−)
None (serum)
19
Not found
Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Whole body FDG-PET Not done
WBC 311/μL Protein 210 mg/ dL Normal
12
Diffuse cerebellar atrophy and brainstem atrophy
(−)
(−)
20
Not found
30
Multifocal subtle leptomeningeal enhancement
WBC 46/ μL (L41, O5)
Normal
None (serum) NMDAR positive (serum)
11
3
Chest & abdomen CT
32
4
6
20
6
132
Normal
(−)
Noneb (serum) Hu positiveb (serum) None (serum)
Mo: month, MRI: magnetic resonance image, CSF: cerebrospinal fluid, NCS: nerve conduction study, NSCLC: non-small cell lung cancer, SCLC: small cell lung cancer, EGC: early gastric cancer, AGC: advanced gastric cancer, CT: computed tomography, FDG-PET: fluoro-deoxyglucose positron emission tomography, HSI: high signal intensity, WBC: white blood cell. a: Amphiphysin antibody was detected in the serum. Antibody testing for Hu, Yo, Ri, Ma2, CV2/CRMP, NMDAR1, AMPAR1, AMPAR2, GABAB-R, LGI1, and CASPR2 was performed. b: Antibody testing only for Hu, Yo, Ri, Ma2 and CV2/CRMP was performed.
postural instability were not improved by treatment with IVIG and steroid pulse therapy, but they improved following treatment with rituximab. The third patient (case #20) persistently suffered from ataxia and postural instability for nearly 1 year after IVIG treatment, but the symptoms improved after treatment with rituximab. Due to the high cost of rituximab, other immunosuppressive agents such as tacrolimus,
tocilizumab, and mycophenolate mofetil were given to the patients following rituximab. In some patients, mycophenolate mofetil or tacrolimus was more effective than rituximab at improving symptoms. Mycophenolate mofetil was given more than six months after rituximab treatment in one patient (case #10), and tacrolimus was prescribed when the patient's symptoms were aggravated after short-term effect
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Table 3 Characteristics of patients with cancer and without cancer.
Patients (n, %) Mean age Sex (M:F) Time between diagnosis of cancer and development of neurological symptoms (mean, range; mo) Time with neurological symptoms but no cancer (mean, range; mo) Immunotherapy (n, %)
With cancer
Without cancer
7 (35%) 71.1 5:2 5.5 (2–11)a –
13 (65%) 50.2 7:6 –
4 (57.1%)
32.2 (2–132) 9 (69.2%)
M: male, F: female, mo: month. a n = 4.
of rituximab in other patient (case #20), which both resulted in significant improvement of the patients' conditions. Modified Rankin Scale (mRS) was assessed in 12 patients before and after the immunotherapy. After treatment, mRS decreased in eight patients, 11 were able to walk unassisted, and one (case #1) died due to an unrelated complication (Table 4, Fig. 1).
4. Discussion This study showed that many patients with amphiphysin autoimmunity develop neurological symptoms instead of SPS and that many of the cases are not associated with cancer. Most of these neurological symptoms improved after immune-modulating therapy. Autoimmune neurological disorder due to amphiphysin antibody should be considered as a potential differential diagnosis in patients who have subacute onset of neurological symptoms without any other cause. When amphiphysin antibody is identified, patients should have an extensive workup to detect cancer even though cancer will not be present in most cases. Immunotherapy should be attempted irrespective of the amount of time since symptom onset. Second-line immunotherapy must be considered when first-line treatment (steroids or IVIG) fails.
Fig. 1. Clinical outcome in patients who underwent immunotherapy. Changes in modified Rankin Score (mRS) before and after the treatment (Tx) are shown in individual patients who underwent immunotherapy (n = 12). The thickness of the line is proportional to the number of the patients who displayed identical change in mRS.
As in a previous report, we found that many patients with amphiphysin autoimmunity have neurological symptoms other than SPS. To date, only one large case series (n = 63) of patients with amphiphysin autoimmunity has been reported. It found the following neurological manifestations of amphiphysin autoimmunity (in order of decreasing frequency): neuropathy (n = 33; 52.4%), encephalopathy (n = 19; 30.2%), SPS (n = 18; 28.6%), myelopathy (n = 17; 27.0%), and cerebellar syndrome (n = 11; 17.5%) (Pittock et al., 2005). The current study also showed that the patients with amphiphysin autoimmunity had a variety of neurological manifestations: limbic encephalitis was the most common neurological symptom (n = 10; 50%). Dysautonomia (n = 9; 45%) and cerebellar dysfunction (n = 6; 30%) were more common than in the previous case series. We designated patients with these neurological symptoms other than SPS as having NSAS. Dysautonomia has not been widely reported in patients with amphiphysin autoimmunity. Although we still do not know the exact
Table 4 Effect of immunotherapy in patients. Patient Immunotherapy (in sequential order)
FU term after treatment (month)
Treatment effect
1 2 3 4 5
IVIG + MPd Not done IVIG + MPd, oral Pd Not done IVIG, rituximab, tacrolimus
0
Decreased seizure, but died due to pulmonary embolism (mRS 4 → 6)
10
Not significant (mRS 2 → 2)
17
Improvement of cognitive impairment (K-MMSE 20 → 25, gradual improvement), gait disturbance (after rituximab) (mRS 4 → 3)
6 7 8 9 10
Not done IVIG + oral Pd IVIG Tacrolimus IVIG + MPd, rituximab, tacrolimus, tocilizumab, mycophenolate mofetil IVIG, oral Pd
8 10 FU loss 14
Improvement of general weakness (assisted gait → self walker-gait) (mRS 4 → 3) Improvement of cognitive impairment (K-MMSE 17 → 22) (mRS 2 → 1)
12 18
Improvement of dysarthria, weakness, and right hand dystonia (mRS 3 → 2)
15 16 17 18
IVIG + MPd Not done IV dexamethasone, IVIG, oral Pd, cyclophosphamide Not done IVIG + MPd Not done IVIG + oral Pd
Improvement of ataxia and postural instability (after rituximab, mycophenolate mofetil) (mRS 4 → 3) Improvement of altered mentality and cranial nerve palsy (significantly after ganciclovir) (mRS 3 → 1) Improvement of dizziness, ataxia (mRS 2 → 1)
13
Improvement of depression, emotional lability, and psychotic symptom (mRS 2 → 2)
5
Improvement of subjective cognitive impairment and irritability (K-MMSE not checked) (mRS 2 → 2)
19 20
Not done IVIG, rituximab, tacrolimus
FU loss 23 (IVIG), 14 (rituximab), 10 (tacrolimus)
11 12 13 14
4
Improvement of ataxia and postural instability (after rituximab, tacrolimus) (mRS 3 → 2)
FU: follow up, IVIG: intravenous immunoglobulin, MPd: intravenous methylprednisolone pulse therapy, Pd: prednisolone, IVIG + MPd: combination therapy, mRS: modified Rankin Scale.
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mechanism of dysautonomia, we think that it is a manifestation of autonomic neuropathy which may be developed by a similar mechanism to that of sensorimotor polyneuropathy. It is also noticeable that neuropathy, which was found in more than half of the patients in the previous report (Pittock et al., 2005), was present in only one-fifth of our patients despite detailed neurological examinations and sufficient diagnostic tests. Reduced presynaptic GABAergic inhibition is believed to be the main pathologic effect of amphiphysin autoimmunity (Geis et al., 2010). The variety of neurological manifestations in patients with amphiphysin autoimmunity may be explained by the widespread distribution of amphiphysin protein and GABAergic neurons. Because amphiphysin is an intracellular synaptic antigen, the epitope is exposed to antibodies during synaptic vesicle fusion and reuptake (Lancaster and Dalmau, 2012). Disrupting amphiphysin function impairs synaptic vesicle endocytosis and reduces the releasable vesicle pool, predominantly in GABAergic neurons. This reduces the GABAergic inhibition and may cause various neurological symptoms (Geis et al., 2010). Amphiphysin autoimmunity seems to be due to both cellular and humoral immune responses (Lancaster and Dalmau, 2012). A few postmortem studies have demonstrated infiltration of cytotoxic T cells in the brain, spinal cord and dorsal root ganglia of patients with amphiphysin autoimmunity (Pittock et al., 2005; Holmøy et al., 2009). In addition, passive transfer of amphiphysin IgG antibody resulted in stiffness, muscle spasm, and behavioral changes in animals (Sommer et al., 2005; Geis et al., 2010, 2012), suggesting that the antibody is pathogenic. According to the previous report, cancer was detected in 79% of patients with amphiphysin autoimmunity (Pittock et al., 2005). In contrast, in our study, underlying cancer was detected in only about one-third of the patients (7/20; 35%); the remainder had neurological symptoms without cancer. Although breast and small cell lung cancer are the most common malignancies associated with anti-amphiphysin syndromes (Pittock et al., 2005), we only detected one case of small cell lung cancer, and instead mostly detected other types of cancer. Accordingly, NSAS, as presented here, might be a non-paraneoplastic manifestation of amphiphysin autoimmunity. A considerable fraction of the patients (8/20; 40%) had neurological symptoms without cancer for more than 2 years. In particular, in case #16, cancer was not detected until 11 years after the onset of neurological symptoms despite extensive screening. It is appreciable that most of the patients (16/20; 80%) developed neurologic syndromes before cancer was detected. Of these, only three (18.8%, cases #4, #5, and #7) were diagnosed with cancer after the antibody was detected. This implies that neurological symptoms caused by amphiphysin antibody can occur without cancer and therefore suspicion of anti-amphiphysin syndrome is important. Many patients with amphiphysin antibody have coexisting autoantibodies (Pittock et al., 2004, 2005). In patients with multiple autoantibodies, determining which antibodies are responsible for clinical syndromes is difficult. Amphiphysin antibody, however, can be present in the absence of other autoantibodies. In our study, only four patients (20%) had coexisting autoantibodies, which is fewer than previously reported (74%) (Pittock et al., 2005). Despite a comprehensive investigation for 12 paraneoplastic antibodies, no other autoantibodies were identified in most of the patients (16/20; 80%), indicating that amphiphysin antibody may be the only evidence for a paraneoplastic neurological syndrome and alone may lead to the identification of an occult neoplasm. In case #4, for example, lung cancer was detected during the diagnostic evaluation of isolated amphiphysin autoimmunity. Our results suggest that neurological syndromes caused by amphiphysin autoimmunity are reversible and that immunotherapy might be helpful even at a late stage. Favorable responses to immunotherapy have been reported in a few cases of SPS associated with amphiphysin autoimmunity (Murinson and Guarnaccia, 2008; Dupond et al., 2010), but the efficacy of immunotherapy in NSAS has not yet been established. A single report of patients with paraneoplastic
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neurological syndromes related to amphiphysin autoimmunity showed neurological improvements in four of five treated with methylprednisolone and two of five treated with IVIG, but which symptoms improved was not described (Pittock et al., 2005). The current report is the first to describe the efficacy of immunotherapy in patients with NSAS. Most of the patients who received immunotherapy (11/13; 84.6%) had favorable responses irrespective of the time since the onset of symptoms. Excluding one patient (case #9) who was lost to follow-up, only one patient (case #3) was not responsive to immunotherapy. On the other hand, remarkably, one patient (case #16) responded to immunotherapy even though treatment was started 10 years after the symptom onset. IVIG and steroids are the most widely used agents for first-line immunotherapy in paraneoplastic neurological syndromes (Viaccoz, 2013). Recently, some studies have shown that second-line immunotherapy (rituximab, cyclophosphamide) is usually effective in antiNMDA receptor encephalitis (Titulaer et al., 2013; Lim et al., 2014). In our study, IVIG and steroids (methylprednisolone or prednisolone) were the most commonly used immunotherapy agents, and most patients had favorable responses to them. However, in some patients, the neurological symptom did not respond to IVIG or steroids and only improved after additional treatment with rituximab (cases #5, #10 and #20). Rituximab is a chimeric monoclonal antibody against protein CD20 and destroys B cells, and therefore is used to treat various autoimmune disorders caused by dysfunctional B cells (Vincent et al., 2011). Only one previous report has documented the effectiveness of rituximab in a patient with amphiphysin-related SPS (Dupond et al., 2010). Here, we describe three patients who were successfully treated with rituximab. Our data suggest that rituximab may be a good choice for second-line immunotherapy in patients with amphiphysin autoimmunity. Interestingly, the therapeutic effect of mycophenolate mofetil or tacrolimus was even better than rituximab in some cases (cases #10 and #20, respectively). Delayed effect of rituximab is unlikely in these cases because of the substantial time gap between two treatments and subsequent aggravation after transient rituximab effect. As mentioned above, the pathogenesis of anti-amphiphysin syndrome is thought to be influenced by both cellular and humoral immunities. Rituximab suppresses B cell function, tacrolimus suppresses T cell function, and mycophenolate mofetil suppresses both. Although individual response differs between these agents, responsiveness to these provides additional support for the involvement of both cellular and humoral immunities in NSAS. Secondary autoimmune disease can occur after viral infection of the central nervous system by herpes simplex virus or Epstein–Barr virus (Pender, 2003; Barzilai et al., 2007; Prüss et al., 2012; Lim et al., 2013; DeSena et al., 2014). Following herpes simplex virus encephalitis, patients frequently have anti-NMDA receptor antibodies (Prüss et al., 2012; DeSena et al., 2014). In our study, amphiphysin antibodies were detected after Epstein–Barr virus encephalitis in two patients. Symptoms in both patients continuously improved in response to immunotherapy following antiviral treatment. We therefore recommend that immune-modulating therapy should be used to control secondary autoimmune processes, including amphiphysin autoimmunity, triggered by viral encephalitis. One limitation of our study is that we have used the immunoblotting method to detect amphiphysin antibody, which is different from the method used by the previous case series study (Pittock et al., 2005). Pittock et al. screened the antibody by using sections of various rodent tissues at first, and then used immunoblotting by using rodent brain extracts and recombinant proteins to confirm the result. The two different approaches might have led to the different patient populations in each study. Our study suggests that anti-amphiphysin syndrome can manifest as non-stiff encephalomyelitis and that it is only partially associated with cancer. Cellular and humoral immunities both appear to play important roles in the pathogenesis of NSAS. Immune-modulating therapies
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