Autoimmune channelopathies in paraneoplastic neurological syndromes

AbstractParaneoplastic neurological syndromes and autoimmune encephalitides are immune neurological disorders occurring or not in association with a cancer. They are thought to be due to an autoimmune reaction against neuronal antigens ectopically expressed by the underlying tumour or by cross-reaction with an unknown infectious agent. In some instances, paraneoplastic neurological syndromes and autoimmune encephalitides are related to an antibody-induced dysfunction of ion channels, a situation that can be labelled as autoimmune channelopathies. Such functional alterations of ion channels are caused by the specific fixation of an autoantibody upon its target, implying that autoimmune channelopathies are usually highly responsive to immuno-modulatory treatments. Over the recent years, numerous autoantibodies corresponding to various neurological syndromes have been discovered and their mechanisms of action partially deciphered. Autoantibodies in neurological autoimmune channelopathies may target either directly ion channels or proteins associated to ion channels and induce channel dysfunction by various mechanisms generally leading to the reduction of synaptic expression of the considered channel. The discovery of those mechanisms of action has provided insights on the regulation of the synaptic expression of the altered channels as well as the putative roles of some of their functional subdomains. Interestingly, patients’ autoantibodies themselves can be used as specific tools in order to study the functions of ion channels. This article is part of a Special Issue entitled: Membrane channels and transporters in cancers

Integration and mining of malaria molecular, functional and pharmacological data: how far are we from a chemogenomic knowledge space?

The organization and mining of malaria genomic and post-genomic data is highly motivated by the necessity to predict and characterize new biological targets and new drugs. Biological targets are sought in a biological space designed from the genomic data from Plasmodium falciparum, but using also the millions of genomic data from other species. Drug candidates are sought in a chemical space containing the millions of small molecules stored in public and private chemolibraries. Data management should therefore be as reliable and versatile as possible. In this context, we examined five aspects of the organization and mining of malaria genomic and post-genomic data: 1) the comparison of protein sequences including compositionally atypical malaria sequences, 2) the high throughput reconstruction of molecular phylogenies, 3) the representation of biological processes particularly metabolic pathways, 4) the versatile methods to integrate genomic data, biological representations and functional profiling obtained from X-omic experiments after drug treatments and 5) the determination and prediction of protein structures and their molecular docking with drug candidate structures. Progresses toward a grid-enabled chemogenomic knowledge space are discussed.Comment: 43 pages, 4 figures, to appear in Malaria Journa

Pregnancy outcomes in anti-NMDA receptor encephalitis: Case series

To report the effects of anti-NMDA receptor (NMDAR) encephalitis in pregnant patients and their babies.We studied a retrospective cohort of patients who developed anti-NMDAR encephalitis during pregnancy or became pregnant while recovering from the encephalitis. In addition, we reviewed the English literature between 2010 and 2019 related to this topic.We studied 11 patients; 6 developed anti-NMDAR encephalitis during pregnancy, and 5 became pregnant while recovering. There were no obstetrical complications, but 6 (55%) babies were premature. Ten newborns were healthy, and 1 (9%) developed transient respiratory distress. Nine infants had assessable follow-up (median 18 months; range, 7-96 months), and all showed normal development. We identified 21 cases in the English literature. Obstetrical complications occurred in 7 (33%) pregnancies. Two patients died of septic shock (1 baby successfully delivered), another 2 had miscarriages, and in 2, the pregnancy was terminated. Sixteen babies (76%) were delivered, 9 (56%) premature. At birth, 13/16 (81%) newborns were healthy, 2/16 (13%) had transient neurologic or respiratory symptoms, and 1 (6%) died of brain edema. Follow-up (median 12 months; range, 6-36 months) was reported for 8 children: 7 (88%) showed normal development and behavior, and 1 (13%) cortical dysplasia. Immunotherapy was used during pregnancy in 7 (64%) of our patients and 18 (86%) of the reported cases, including rituximab in 4 cases, without adverse effects.Patients who develop anti-NMDAR encephalitis during pregnancy or become pregnant during recovery often have obstetrical complications, but most of the newborns are healthy and appear to have normal development.Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology

Mononeuritis multiplex following immune checkpoint inhibitors in malignant pleural mesothelioma

IntroductionMononeuritis multiplex is frequently related to vasculitic neuropathy and has been reported only sporadically as an adverse event of immune checkpoint inhibitors.MethodsCase series of three patients with mononeuritis multiplex—all with mesothelioma—identified in the databases of two French clinical networks (French Reference Center for Paraneoplastic Neurological Syndromes, Lyon; OncoNeuroTox, Paris; January 2015–October 2022) set up to collect and investigate n-irAEs on a nationwide level.ResultsThree patients (male; median age 86 years; range 72–88 years) had pleural mesothelioma and received 10, 4, and 6 cycles, respectively, of first-line nivolumab plus ipilimumab combined therapy. In patient 1, the neurological symptoms involved the median nerves, and in the other two patients, there was a more diffuse distribution; the symptoms were severe (common terminology criteria for adverse events, CTCAE grade 3) in all patients. Nerve conduction studies indicated mononeuritis multiplex in all patients. Peripheral nerve biopsy demonstrated necrotizing vasculitis in patients 1 and 3 and marked IgA deposition without inflammatory lesions in patient 2. Immune checkpoint inhibitors were permanently withdrawn, and corticosteroids were administered to all patients, leading to complete symptom regression (CTCAE grade 0, patient 2) or partial improvement (CTCAE grade 2, patients 1 and 3). During steroid tapering, patient 1 experienced symptom recurrence and spreading to other nerve territories (CTCAE grade 3); he improved 3 months after rituximab and cyclophosphamide administration.DiscussionWe report the occurrence of mononeuritis multiplex, a very rare adverse event of immune checkpoint inhibitors, in the three patients with mesothelioma. Clinicians must be aware of this severe, yet treatable adverse event

Paraneoplastic cerebellar ataxia and antibodies to metabotropic glutamate receptor 2

To report the presence of a new neuronal surface antibody against the metabotropic glutamate receptor 2 antibody (mGluR2-Ab) in 2 patients with paraneoplastic cerebellar ataxia.mGluR2-Abs were initially characterized by immunohistochemistry on the rat brain and confirmed by immunofluorescence on HEK293 cells transfected with mGluR2. Additional studies included analysis of potential cross-reactivity with other mGluRs, expression of mGluR2 in patients' tumors, and the effects of mGluR2-Abs on cultures of rat hippocampal neurons.Patient 1 was a 78-year-old woman with progressive cerebellar ataxia with an initial relapsing-remitting course who developed a small-cell tumor of unknown origin. Patient 2 was a 3-year-old girl who presented a steroid-responsive acute cerebellitis preceding the diagnosis of an alveolar rhabdomyosarcoma. Patients' serum and CSF showed a characteristic immunostaining of the hippocampus and cerebellum in rat brain sections and immunolabeled the cell surface of live rat hippocampal neurons. HEK293 cells transfected with mGluR1, 2, 3, and 5 confirmed that patients' antibodies only recognized mGluR2. mGluR2-Abs were not detected in 160 controls, 120 with paraneoplastic, autoimmune, or degenerative ataxias, and 40 with autoimmune encephalitis and antibodies against mGluR5 or unknown antigens. Expression of mGluR2 in tumors was confirmed by immunohistochemistry using a commercial mGluR2-Ab. Incubation of live rat hippocampal neurons with CSF of patient 2 did not modify the density of surface mGluR2 clusters.mGluR2-Abs are a novel biomarker of paraneoplastic cerebellar ataxia. The potential pathogenic effect of the antibodies is not mediated by downregulation or internalization of neuronal surface mGluR2.Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology

Placental transfer of NMDAR antibodies causes reversible alterations in mice

Objective: To determine whether maternofetal transfer of NMDA receptor (NMDAR) antibodies has pathogenic effects on the fetus and offspring, we developed a model of placental transfer of antibodies. Methods: Pregnant C57BL/6J mice were administered via tail vein patients' or controls' immunoglobulin G (IgG) on days 14-16 of gestation, when the placenta is able to transport IgG and the immature fetal blood-brain barrier is less restrictive to IgG crossing. Immunohistochemical and DiOlistic (gene gun delivery of fluorescent dye) staining, confocal microscopy, standardized developmental and behavioral tasks, and hippocampal long-term potentiation were used to determine the antibody effects. Results: In brains of fetuses, patients' IgG, but not controls' IgG, bound to NMDAR, causing a decrease in NMDAR clusters and cortical plate thickness. No increase in neonatal mortality was observed, but offspring exposed in utero to patients' IgG had reduced levels of cell-surface and synaptic NMDAR, increased dendritic arborization, decreased density of mature (mushroom-shaped) spines, microglial activation, and thinning of brain cortical layers II-IV with cellular compaction. These animals also had a delay in innate reflexes and eye opening and during follow-up showed depressive-like behavior, deficits in nest building, poor motor coordination, and impaired social-spatial memory and hippocampal plasticity. Remarkably, all these paradigms progressively improved (becoming similar to those of controls) during follow-up until adulthood. Conclusions: In this model, placental transfer of patients' NMDAR antibodies caused severe but reversible synaptic and neurodevelopmental alterations. Reversible antibody effects may contribute to the infrequent and limited number of complications described in children of patients who develop anti-NMDAR encephalitis during pregnancy

Updated Diagnostic Criteria for Paraneoplastic Neurologic Syndromes

The contemporary diagnosis of paraneoplastic neurologic syndromes (PNSs) requires an increasing understanding of their clinical, immunologic, and oncologic heterogeneity. The 2004 PNS criteria are partially outdated due to advances in PNS research in the last 16 years leading to the identification of new phenotypes and antibodies that have transformed the diagnostic approach to PNS. Here, we propose updated diagnostic criteria for PNS.A panel of experts developed by consensus a modified set of diagnostic PNS criteria for clinical decision making and research purposes. The panel reappraised the 2004 criteria alongside new knowledge on PNS obtained from published and unpublished data generated by the different laboratories involved in the project.The panel proposed to substitute "classical syndromes" with the term "high-risk phenotypes" for cancer and introduce the concept of "intermediate-risk phenotypes." The term "onconeural antibody" was replaced by "high risk" (>70% associated with cancer) and "intermediate risk" (30%-70% associated with cancer) antibodies. The panel classified 3 levels of evidence for PNS: definite, probable, and possible. Each level can be reached by using the PNS-Care Score, which combines clinical phenotype, antibody type, the presence or absence of cancer, and time of follow-up. With the exception of opsoclonus-myoclonus, the diagnosis of definite PNS requires the presence of high- or intermediate-risk antibodies. Specific recommendations for similar syndromes triggered by immune checkpoint inhibitors are also provided.The proposed criteria and recommendations should be used to enhance the clinical care of patients with PNS and to encourage standardization of research initiatives addressing PNS.Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology

Syndromes neurologiques associés aux anticorps anti-CASPR2 : caractérisation phénotypique et corrélations immuno-cliniques

Antibodies against CASPR2 (Contactin-2 Associated Protein), a neuroglial cell-adhesion protein, have been described in at least three neurological syndromes: autoimmune limbic encephalitis, acquired neuromyotonia (or Isaacs' syndrome) and Morvan syndrome. However, the clinical phenotype associated with anti-CASPR2 antibodies is not yet completely understood. In addition, some authors consider that instead of specific syndromes, anti-CASPR2 antibodies associate with a set of core symptoms that combine randomly in the patients. Last, the pathophysiologic factors underpinning clinical variability in the anti-CASPR2 antibodies patients are unknown. In this PhD project, we use a nationwide, retrospective cohort of anti-CASPR2 antibodies patients, in order to address the issue of the clinical characterization of anti-CASPR2 antibodies patients. We aimed at describing the clinical presentation of CASPR2 encephalitis and Morvan syndrome, studying the outcomes of CASPR2 encephalitis, and analyzing the repartition of the patients' symptoms in order to assess if the symptoms are distributed randomly or if instead they form distinct clinical patterns. The present PhD project is divided into three studies. In the first study, we analyze clinical presentations and outcomes of anti-CASPR2 antibodies patients with limbic encephalitis. We observe that most patients were males from 50 to 75 years old, and frequently had extra-limbic symptoms, such as cerebellar ataxia. In addition, response to immunotherapy was good, even though 25% of the patients did not return to baseline and were left with residual symptoms, including cognitive disturbances, epilepsy, and cerebellar ataxia. In the second study, we describe the first reported cases of autoimmune episodic ataxia, a novel symptom that so far has been found only in anti-CASPR2 antibody associated autoimmune limbic encephalitis patients. It consists in transient episodes of paroxysmal ataxia, and is reminiscent of hereditary episodic ataxia. Interestingly, we found in two patients rare variants of CACNA1A and KCNA1, two genes involved in the main types of hereditary episodic ataxia. While the impact of these variants on ion channel functions is unknown, it raises the question of the role of the genetic background in phenotype determination in anti-CASPR2 antibodies patients. In the third study, we use a statistical cluster analysis to assess anti-CASPR2 antibodies patients' symptoms combinations. We found that the symptoms do not form random combinations, but that instead clinical patterns can be identified, which correspond to patients with limbic encephalitis, Morvan syndrome, and neuromyotonia. In addition, we confirm the expansive clinical presentation of limbic encephalitis, since more than a third of the patients had non-limbic symptoms such as cerebellar ataxia, dysautonomia, weight loss, and movement disorders. Notably, less than ten percent of the patients had a combination of neuromyotonia and limbic symptoms. Finally, the Morvan syndrome patients had severe peripheral nerve hyperexcitability features, severe dysautonomia, severe insomnia, weight loss, and frequently had a malignant thymoma. This clinical classification into three specific syndromes is supported by differences in term of autoantibody specificities, as limbic encephalitis patients tended to have higher anti-CASPR2 antibodies levels and were more frequently cerebrospinal fluid-positive, and by the genetic background, since the Morvan syndrome patients did not have the HLA DRB1*1101 association that is found in limbic encephalitis patients. In conclusion, the present PhD project supports the view that anti-CASPR2 antibodies patients can be classified into three specific syndromes, autoimmune limbic encephalitis, neuromyotonia, and Morvan syndrome. Differences in etiopathogeny likely account for the clinical variability observed in anti-CASPR2 antibodies patientsLes auto-anticorps dirigés contre CASPR2 (Contactin-2 Associated Protein), une protéine d'adhésion neuro-gliale, ont été décrits dans au moins trois syndromes neurologiques auto-immuns: l'encéphalite limbique auto-immune, la neuromyotonie acquise et le syndrome de Morvan. Cependant, le phénotype clinique associé aux anticorps anti-CASPR2 demeure imparfaitement décrit. Ce travail de thèse vise à décire les présentations cliniques des patients avec anticorps anti-CASPR2. La première étude est consacrée à l'analyse de la présentation clinique et du pronostic de l'encéphalite limbique auto-immune à anticorps anti-CASPR2. Nous observons que la majorité des patients sont des hommes âgés de 50 à 75 ans, et ont fréquemment des symptômes extra-limbiques, en particulier une ataxie cérébelleuse. Ces patients répondent le plus souvent aux immunothérapies, bien qu'un quart des patients garde des séquelles cognitives, une épilepsie, ou une ataxie. Dans la seconde étude, nous décrivons pour la première fois l'ataxie épisodique auto-immune, un symptôme jusqu'ici exclusivement associé à l'encéphalite auto-immune avec anticorps anti-CASPR2. Ce symptôme est similaire aux ataxies épisodiques héréditaires et, de façon remarquable, nous avons décelé chez 2 patients un polymorphisme rare des gènes KCNA1 ou CACNA1A, qui sont impliqués respectivement dans l'ataxie épisodique de type 1 et de type 2. Bien que l'impact de ces variants rare sur la fonction des canaux ioniques qu'ils codent est inconnu, ces observations soulèvent la question de l'influence du terrain génétique sur la détermination du phénotype neurologique des patients avec anticorps anti-CASPR2. Dans la troisième étude, nous réalisons une analyse typologique des symptômes des patients dans le but de vérifier si les symptômes se distribuent de façon aléatoire ou au contraire forment des profils cliniques spécifiques. Par cette méthode, nous démontrons que les symptômes s'associent de façon non-aléatoire, permettant de classer les patients en trois groupes distincts, qui correspondent à l'encéphalite limbique auto-immune, à la neuromyotonie, et au syndrome de Morvan. De plus nous confirmons la grande variété de présentation clinique de l'encéphalite à anticorps anti-CASPR2, qui ne se limite pas à la présence de symptômes limbiques, puisque plus d'un tiers de patients présente également des symptômes extra-limbiques, tels que l'ataxie cérébelleuse, la dysautonomie, la perte de poids, ou des mouvements anormaux. De façon notable, moins de dix pour cent des patients avaient une combinaison de symptômes limbiques et de neuromyotonie. Enfin, le syndrome de Morvan se caractérise dans notre série par des signes sévères d'hyperexcitabilité nerveuse périphérique, des signes sévères de dysautonomie, une insomnie sévère, une perte poids fréquente, et une association au thymome malin. Cette classification clinique en trois syndromes est confortée par des variations des caractéristiques des auto-anticorps, puisque les patients avec une encéphalite limbique ont des titres sériques d'anticorps anti-CASPR2 plus élevés, et des anticorps anti-CASPR2 détectable plus souvent dans le liquide céphalo-rachidien, ainsi que par des différences en terme d'haplotype HLA associé, puisque les patients avec un syndrome de Morvan ne sont pas porteurs de l'haplotype HLA DRB1*1101 qui est retrouvé chez les patients avec une encéphalite limbique à anticorps anti-CASPR2. En conclusion, ce travail de thèse conforte la notion que les patients avec anticorps anti-CASPR2 présentent des syndromes spécifiques, l'encéphalite limbique, la neuromyotonie acquise, et le syndrome de Morvan. La variabilité clinique observée avec les anticorps anti-CASPR2 est vraisemblablement liée à l'existence de mécanismes physiopathologiques différents selon les syndrome

TULIP software and web server : automatic classification of protein sequences based on pairwise comparisons and Z-value statistics

A configuration space of homologous protein sequences (or CSHP) has been recently constructed based on pairwise comparisons, with probabilities deduced from Z-value statistics (Monte Carlo methods applied to pairwise comparisons) and following evolutionary assumptions. A Z-value cut-off is applied so as proteins are placed in the CSHP only when the similarity of pairs of sequences is significant following the Theorem of the Upper Limit of a score Probability (TULIP theorem). Based on the positions of similar protein sequences in the CSHP, a classification can be deduced, which can be visualized as trees, called TULIP trees. In previous case studies, TULIP trees where shown to be consistent with phylogenetic trees. To date, no tool has been made available to allow the computation of TULIP trees following this model. The availability of methods to cluster proteins based on pairwise comparisons and following evolutionary assumptions should be useful for evaluation and for the future improvements they might inspire. We developed a web server allowing the local or online computation of TULIP trees based on the CSHP probabilities. The input is a set of homologous protein sequences in multi-FASTA format. Pairwise comparisons are conducted using the Smith-Waterman method, with 100-1,000 sequence shuffling to estimate pairwise Z-values. Obtained Z-value matrix is used to infer a tree which is then written to a file. Output consists therefore of a Z-value matrix, a distance matrix, a TULIP treefile in NEWICK format, and a TULIP tree visualisation. The TULIP server provides an easy-to-use interface to the TULIP software, and allows a classification of protein sequences based on pairwise alignments and following evolutionary assumptions. TULIP trees are consistent with phylogenies in numerous cases, but they can be inconsistent for multi-domain proteins in which some domains have been conserved in all branches. Thus TULIP trees cannot be considered as conventional phylogenetic trees, following the MIAPA (Minimum Information About a Phylogenetic Analysis) recommendations. A major strength of the TULIP classification is its statistical validity when analysing samples including compositionally unbiased and biased sequences (i.e. with biased amino acid distributions), like sequences from Plasmodium falciparum. The TULIP web server is a service of the Malaria Portal of the University of Pretoria, South Africa, and is available at http://malport.bi.up.ac.za/TULIP