Matteo Gastaldi

IRCCS C Mondino Neuroimmunology laboratory

University of Pavia

XXIX OTTORINO ROSSI AWARD CERIMONYPavia, 12 Dicembre 2018

Autoimmune encephalitis and neuronal surface

antibodies

An Italian retrospective study

• Psychiatric symptoms

• Seizures

• Encephalopathy

• Movement disorders

• Dysautonomia

Antibody mediated encephalitis (NMDAR)

Courtesy of Prof A. Vincent

Ann Neurol 2010

NMDAR antibodies defined the etiology of unexplained psychiatric syndromes

Pathogenic antibody removal leads to clinical recovery

Gastaldi et al, Neurotherapeutics 2016

Pre-treatment

Post-treatment

N Engl J Med 2018;378:840

1980 2000 2005 2010 2015

HuNMDAR

GLYR

AMPAR

LGI1/CASPR2

GABABR

mGluR5

D2R

DPPX

GABAAR

IgLON5

Neu3a

• disorders characterized by symptoms of limbic and extra-limbic dysfunction (psychiatric

manifestations)

• encephalitis annual incidence of 2-3/100,000, 20 % are immune mediated [Neurology

2010;75:1735]

• no brain-imaging modalities or biomarkers specific of these disorders other than the

demonstration of the neuronal antibodies

Conformational

antigenLinearized antigen

Neuronal surface antibodies are conformational

Antibodies recognize

discontinous epitopes that

depend on the preservation

of the tertiary structure

Cell based assay Immunohistochemistry on rat

brain

Neuronal cultures

Graus 2016 criteria for AE

Lancet Neurol, 2016

POSSIBLE AUTOIMMUNE ENCEPHALITIS: early treatment can be

started before antibody results

NEGATIVE LIMBIC/PROBABLE AUTOIMMUNE ENCEPHALITIS:

diagnosis can be made without autoantibodies

STUDY PROPOSAL-AIMS:

- to validate the criteria in a large retrospective cohort of AE

- to define the clinical characteristics of seronegative AE

Pavia (Neurologia, IRCCS C. Mondino)

Pavia (Pediatria S.Matteo)

Voghera (Neurologia, Ospedale Civile)

Bologna (Neurologia, Bellaria)

Citta’ di Castello (Neurologia)

Milano (Pediatria, Buzzi)

Genova (Neurologia, San Martino)

Genova (Pediatria, Gaslini)

Varese (Neurologia, Osp. di Circolo)

Firenze (Neurologia, Careggi)

Roma (Neurologia, Gemelli)

Roma (Pediatria, Bambin Gesu’)

Padova (Neurologia, Snt’Antonio)

Padova (Pediatria, Az. Ospedaliera)

Perugia (Neurologia, Az. Ospedaliera)

Trento (Neurologia, Santa Chiara)

Treviso (Neurologia, ULSS)

Verona (Neurologia, Borgo Roma)

MethodsRetrospective multicenter study (14 neurology/pediatric

hospitals, 2014-2016)

INCLUSION CRITERIA

• Patients fulfilling criteria for “possible autoimmune encephalitis”

according to Graus 2016

– Subacute onset of memory impairment, altered consciousness or

psychiatric symptoms

– One of the following

• New onset focal neurological signs

• New onset seizures

• CSF pleocytosis (>5 cells/mm3)

• MRI alterations suggestive of autoimmune encephalitis Pleiocitosi

liquorale (> 5 leucociti/mm3)

– Exclusion of alternative causes

• Anti-SNC antibodies tested during the symptomatic phase

• ADEM and Bickerstaff encephalitis were not included in the study

Methods

Outline of the study

LE was the most common clinical syndrome (overall 48.3% of patients), followed by

NMDAR encephalitis (26.7%)

Demographic distribution

0 20 40 60 80 1000

5

10

15

20

25

Age at onset

N o

f pat

ient

s ALL

NMDARALL LE

NM

DA

R

PO

SS

-AE

PR

OB

-AE

PO

S-L

E

NE

G-L

E

DE

F-A

E

0

50

100

% o

f pat

ient

s

PediatricAdult

• M:F=1:1

• Age range: 3 months-90 years

• Bimodal distribution that

reflected the age range in

NMDAR encephalitis and LE

• 29 (24.2%) were pediatric

• Pediatric patients were mostly

distributed in NMDAR, and

POSS/PROB AE, and nearly

absent in LE

Clinical dataSymptoms were different according to the diagnostic group

• Seizures and memory impairment were predominant in the

LE group (p=0.001)

• Movement disorders, psychiatric symptoms and

dysautonomia were more common in NMDAR (p=0.001)

Total=24

25.00% Thymoma

8.33% Lymphoma

8.33% Lung

8.33% Testicle8.33% Breast

12.50% Other

12.50% Ovarian teratoma

16.67% NET

• 24/120 patients (20%) had a tumor

• Most common tumors were thymoma and neuroendocrine

Memor

y

Seizur

es

Dysau

tonom

ia

Mov

Dis

Psych

i atri

c0

20

40

60

80

100

%of

pat

ient

s

NMDARPOS-LE

NEG-LE

POSS-AE

PROB-AE

DEF-AE

Anti-neuronal surface antibodies detection

“First line” diagnostic(Commercial CBA)

NMDAR, LGI1, CASPR2,

GABAB, AMPAR 1-2

“Second line” diagnostic(Live/fixed in-house CBA, Staining on murine tissue,

live hippocampal neurons)

Second line test allowed

the identification of

relevant antibodies in 12

patients (31.6% of

negative)

AMPAR=1

GABAA=3

IgLON5=1

GLYr=1

Uncharacterized=6 0 10 20 30 40

IgLON5

GLY

GABA B

Ma2

GABA A

Caspr2+LGI1

Hu

GAD

Unc-SNAbs

Caspr2

LGI1

NMDAR

N of patients

Total N of patients= 83

Memor

y

Seizur

esDys

auto

nom

ia

Mov D

is

Psych

iatric

Relapse

s

Tumo r

Bil at M

RI

0

20

40

60

80

100

%of

pat

ient

s

POS-LENEG-LE

Patients with with POS vs NEG Limbic Encephalitis

• POS-AE and NEG-AE were remarkably similar in both clinical presentation,

relapse risk and tumor frequency

• Memory impairment was found in 84.5% of patients, and seizures in 71.9%

• NEG-LE patients (as per definition) showed more frequently bilateral lesions on

MRI (15/17- 2 patients had bilateral involvement on PET scan) (p=0.01)

• The 3 patients in NEG-LE group with tumor had breast cancer (n=1), renal

carcinoma (n=1) and mucoepidermoid carcinoma of the jaw (n=1)

**

Probable and possible AE• 20/120 patients

• 11/20 patients had an LE-like phenotype (=seizures + memory impairment + behavioral

abnormalities)

• Seizures were frequent (11/20, 55% of patients) and 4/20 had status epilepticus (20%)

• 65% of patients had an inflammatory CSF (OCB in 8/20)

• All patients with PROB-AE had a combination of inflammatory CSF and MRI abnormalities (as

per definition criteria)

• MRI pattern involved temporomesial

structures in 4/20 patients (monolateral)

• Other MRI pattern included T2 hyperintense

cortical lesions (C) or multifocal subcortical

lesions (D)F. Massa and L. Benedetti

Treatment

• 94/111 patients responded to treatment

(88% in POS-AE vs 56.8 in NEG-AE, p=0.001)

• Treatment regimen was different between

NEG-AE and POS-AE (second line in only

4/37)

FIRST LINE

111/120 (84.2%)

COMBINED FIRST LINE

(Steroids + IvIg/PlEx)

84/111 (75.7%)

SECOND LINE

(RTX and/or CPA)

28/111 (25.2%)

POS-AE

NEG-AE

0

50

100

% o

f pat

ient

s

No treatmentFirst lineSecond line

*

POS-AE

NEG-AE

0

50

100

% o

f pat

ient

s Responders

Non responders

***

Time to treatment in POS vs NEG AE

POS-AE

NEG-AE

0

50

100

% o

f pat

ient

s

Time to treatment

>6 months

<6 months

***

Time to treatment was longer

in NEG-AE (p=0.001)

Longer latency to treatment

were associated with poor

response (p=0.001)

0 10 20 30 40 50 200

800

5

10

15

20

25

30

35

40

45

50

55

60

Time to treatment (weeks)

Pat

ient

N

0 10 20 30 40 50 200

800

5

10

15

Time to treatment (weeks)

Pat

ient

N

First lineNo treatment

Second line

0 10 20 30 40 50 200

800

5

10

Time to treatment (weeks)

Pat

ient

N

0 10 20 30 40 50 200

800

5

10

Time to treatment (weeks)

Pat

ient

N

A

C

D B

POS-AE (responders)

POS-AE (non-responders)

NEG-AE (responders)

NEG-AE (non responders)

Final outcome and relapses

• 19/120 patients (15.8%) relapsed (median time 7 months, range 1-18) and 37/120 (31.9%)

had a MRS>/=3

• 35% of patients required admission to the ICU

• Relapse rate and tumor frequency was similar in POS-AE vs NEG-AE

• Poor outcome was found in 37/120 patients (31.9%), slightly more frequent in NEG-AE

• 6/120 patients died (5 with POS-LE and 1 with NMDAR)

• Factors associated with poor outcome were status epilepticus (p=0.02) and treatment

received (p=0.02)

Relapse

s

Tumo r

mRS>2

0

20

40

60

80

100

%of

pat

ient

s

POS-LENEG-LE

Conclusions

• NEG-AE (and particularly NEG-LE) has similar

relapse rate and tumor frequency compared

to POS-AE

• 56.8% OF NEG-AE responds to immune

therapy. More aggressive and timely

treatments could further improve the

outcome

• Second line tests for anti-neuronal antibodies (in-house techniques) allow the characterization of 1/3 of the seronegativepatients

Diego Franciotta

Silvia Scaranzin

Martina Vigorito

Elisabetta Zardini

matteo.gastaldi@mondino.it

BOLOGNA

Maria Pia

Giannoccaro

Rocco Liguori

CITTA DI CASTELLO

Stefano Ricci

FIRENZE

Silvia Casagrande

Luca Massacesi

GENOVA (San

Martino)

Luana Benedetti

Federico Massa

Caterina Lapucci

Antonio Uccelli

GENOVA (Gaslini)

Thea Giacomini

Margherita Mancardi

Edvige Veneselli

MILANO (Buzzi)

Stefania Bova

PADOVA-TREVISO-

TRENTO

Marco Zoccarato

Luigi Zuliani

Bruno Giometto

PADOVA (Pediatria)

Margherita Nosadini

Stefano Sartori

PAVIA (Pediatria)

Thomas Foiadelli

Salvatore Savasta

PAVIA

Enrico Marchioni

Paola Bini

Luca Diamanti

Giulia Berzero

PERUGIA

Massimiliano Di Filippo

ROMA (Gemelli)

Raffaele Iorio

Amelia Evoli

ROMA (Bambin Gesù)

Massimiliano Valeriani

Laura Papetti

Federico Vigevano

VARESE

Marco Mauri

Giorgio Bono

Maurizio Versino

VERONA

Sara Mariotto

Sergio Ferrari

VOGHERA

Carla Arbasino

Carlo Dallocchio

Neuroimmunology

Laboratory

IRCCS Mondino

Foundation, Pavia

LIMBIC ENCEPHALITIS ( Corsellis, 1968)• Seizures• Memory impairment• Behavioral abnormalities

“AUTOIMMUNE ENCEPHALITIS” • Psychiatric symptoms (NMDAR)• Seizures and status epilepticus (GABAa)• Movement disorders (D2R, NMDAR)• Peripheral nervous system (CASPR2)

Autoimmune encephalitis

Dalmau, 2017

Anti-neuronal antibodies and AE

Onco-neural antibodies Neuronal surface antibodies

Dalmau, 2017

• Target Intracellular antigens (Hu, Yo, Ri,

Ma2)

• Abs are not pathogenic (T-cell mediated

damage)

• Almost invariably associated with tumor

• Neurological syndrome not responding

to immunosuppressive therapies

• Surface antigens (NMDAR, LGI1,

CASPR2, AMPAR)

• Abs are pathogenic

• Not strictly paraneoplastic

• Neurological syndrome responds to

immunosuppressive therapy

Conformational Linearized antigen

Anti neuro-glial surface antigens-Abs1) Neuroglial Surface Abs are “conformational”