Autoantibodies in Neurological Diseases

Autoantibodies in neurological diseases

Hu, Ri, Yo, Tr CV2 Amphiphysin Amphiphysin GM1 Ma/Ta CV2 Amphiphysin Cerebellum Intestine Hippocampus Control transfection CV2 GM2 SOX1 PNMAP 2 (MMa2/Ta) Zic4 PNMP A2 GM3G ITPR1 (MMa2/Ta) RiR CARP YoY RiR GD1G a GAD Hippocampus HEp-2 cells Cerebellum NMDAR (transf. cells) Recoverin HuH Titin Anti-Hu positive Anti-NMDA-receptor positive YoY GD1G b Recoverin Gangliosides MAG HuH GT1b SOS X1 Myelin Aquaporin-4 Titin GQ1G b MOG Cerebellum Intestine Cerebellum Control transfection Zic4 VGKC (LGI1 + CASPR2) NMDA receptors GAD65G AMPA receptors Tr (DNER) GABAB receptors DPPX Control CoC ntrol CoC ntrol Hippocampus HEp-2 cells Optic nerve AQP-4 (transf. cells) IgLON5 Glycine receptors Anti-Yo positive Anti-aquaporin-4 positive AChR

Indirect immunoﬂ uorescence EUROLINE Examples of relevant target antigens

EUROIMMUN AG · Seekamp 31 · 23560 Lübeck (Germany) · Tel +49 451/5855-0 · Fax 5855-591 · [email protected] · www.euroimmun.com 2 Autoantibodies IIFT pattern Test systems

Anti-Hu (ANNA-1*) IIFT: Granular ﬂ uorescence of almost all neuronal nuclei on the substrates cerebellum and hippocampus. The Autoantibodies against basic, RNA- cell nuclei of the plexus myentericus (intestinal tissue) binding proteins of the neuronal cell are also positive. nuclei of the central and peripheral nervous system EUROLINE: Positive reaction of the recombinant Hu antigen (HuD). Associated diseases: encephalomyelitis, subacute sensory neuronopathy (Denny-Brown syndrome), autonomous neuropathy

Associated tumours: small-cell lung carcinoma, Cerebellum Intestine neuroblastoma

Anti-Ri (ANNA-2*) IIFT: Granular ﬂ uorescence of almost all neuronal nuclei on the substrates cerebellum and hippocampus. The Autoantibodies against neuronal cell substrate intestine (plexus myentericus) shows no reac- nuclei of the central nervous system tion. (CNS) EUROLINE: Positive reaction of the recombinant Ri anti- Associated disease: opsoclonus myoclonus syn- gen (NOVA1***). drome

Associated tumours: small-cell lung carcinoma, breast carcinoma

Cerebellum Intestine

Anti-Yo (PCA-1**) IIFT: Cytoplasmic fl uorescence of the Purkinje cells on the substrate cerebellum and of individual cells in Autoantibodies against antigens the hilus of the hippocampus. The substrate intestine in the cytoplasm (rough ER, Golgi (plexus myentericus) shows no specifi c reaction. apparatus, cytoplasmic membrane) of Intestine the cerebellar Purkinje cells Monospecifi c test using Yo/CDR2-transfected HEK**** cells Associated disease: cerebellar degeneration

Associated tumours: ovarian carcinoma, breast EUROLINE: Positive reaction of the recombinant Yo carcinoma, uterine carcinoma antigen (CDR62*****). Cerebellum Yo (transf. cells)

*ANNA = anti-neuronal nuclear antibodies **PCA = Purkinje cell autoantibodies ***NOVA = neuronal onconeural ventral nervous system antigen ****HEK = human embryonic kidney ***** CDR = cerebellar degeneration-related antigen 3 Autoantibodies IIFT pattern Test systems

PCA-2* IIFT: Fluorescence of the cytoplasm of the cerebellar Purkinje cells, which extends into the dendrites. Autoantibodies against a 280 kDa protein of the cerebellar Purkinje cells

Associated diseases: limbic/brain stem encephalitis, cerebellar ataxia, Lambert-Eaton myasthenic syndrome (LEMS), autonomous neuropathy, motor neuropathy

Associated tumours: gynaecological tumours, small- cell lung carcinoma Cerebellum

Anti-Tr Coarse granular ﬂ uorescence of the cytoplasm of the cerebellar Purkinje cells, dot-like staining of the Autoantibodies against DNER** protein molecular layer. in the Purkinje cells of the cerebellum Monospeciﬁ c test using DNER-transfected HEK cells. Associated disease: cerebellar degeneration

Associated tumour: Hodgkin‘s lymphoma EUROLINE: Positive reaction of the speciﬁ c target antigen Tr (DNER).

Cerebellum DNER (transf. cells)

Anti-CARP (anti-carbonic anhydrase- IIFT: The molecular layer and the cytoplasm of the related protein VIII) Purkinje cells in the cerebellum show a dotted to ﬁ ne- speckled pattern. Autoantibodies against CARP VIII in the Purkinje cell layer of the Monospeciﬁ c test using CARP VIII-transfected HEK cells. cerebellum

Associated diseases: paraneoplastic cerebellar degeneration, cerebellar ataxia

Associated tumours: melanoma, ovarian carcinoma Cerebellum CARP (transf. cells)

*PCA = Purkinje cell autoantibodies **DNER = delta/notch-like epidermal growth factor-related receptor 4 Autoantibodies IIFT pattern Test systems

Anti-ITPR1 (Anti-Sj) IIFT: The molecular layer and the cytoplasm of the (anti-Sj / inositol 1,4,5-trisphosphate Purkinje cells in the cerebellum show a dotted to ﬁ ne- receptor) speckled pattern.

Autoantibodies against ITPR1 in Monospeciﬁ c test using ITPR1-transfected HEK cells. Purkinje cells of the cerebellum

Associated disease: cerebellar ataxia

Associated tumour: NSCLC in an unpublished case

Cerebellum ITPR1 (transf. cells)

Anti-glia nuclear antibodies (AGNA) IIFT: Fluorescence of the cell nuclei of the Bergmann glia in the Purkinje cell layer of the cerebellum. Possible antigen: SOX1

Associated diseases: paraneoplastic Lambert- Eaton myasthenic syndrome (LEMS), cerebellar degeneration, sensory neuropathy

Associated tumour: small-cell lung carcinoma

Cerebellum

Anti-Ma (Ma1, Ma2/Ta) IIFT: Reaction of the nerve cell nucleoli on the substrates cerebellum, cerebrum and hippocampus. Autoantibodies against Ma1 (PNMA1*; 37 kDa) and Ma2/Ta (PNMA2*; 40 kDa), EUROLINE: Anti-Ma (Ma1 and Ma2/Ta) antibodies proteins in the nucleoli of the neuronal produce a positive reaction with the recombinant Ma2/ cell nuclei Ta (PNMA2*) antigen.

Associated diseases: brain stem encephalitis, limbic encephalitis

Associated tumours: lung carcinoma, testicular carcinoma (esp. Ma2/Ta), breast carcinoma Cerebellum Cerebrum

PNMA1/2 = paraneoplastic antigen Ma1/2 5 Autoantibodies IIFT pattern Test systems

Anti-CV2 IIFT: Sand-like ﬂ uorescence on the substrate cerebellum, most visible in the stratum moleculare. Autoantibodies against CV2, a 66-kDa protein EUROLINE: Positive reaction of the recombinant CV2.

Associated diseases: sensory and autonomous neuropathy, encephalitis, extrapyramidal motor syndrome, cerebellar degeneration

Associated tumours: small-cell lung carcinoma, thymoma

Cerebellum

Anti-amphiphysin IIFT: Fluorescence of the presynaptic nerve ends in the cerebellum. The nerve dendrites of the stratum Autoantibodies against amphiphysin, moleculare show a more intense fl uorescence than the a synaptic protein with a molecular stratum granulosum. The fl uorescence pattern of the weight of 128 kDa stratum granulosum resembles the pattern found with antibodies against GAD. Associated disease: paraneoplastic stiff-person syndrome EUROLINE: Positive reaction of the specifi c target Associated tumours: breast carcinoma, small-cell antigen amphiphysin. lung carcinoma

Cerebellum

Anti-GAD IIFT: Patchy fl uorescence of the stratum granulosum on the substrates cerebellum and hippocampus. Autoantibodies against the enzyme Fluorescence of the pancreas islets on the substrate glutamic acid decarboxylase pancreas. GAD (transf. cells) Associated diseases: stiff-person syndrome, limbic Monospecifi c test using GAD-transfected HEK cells. encephalitis EUROLINE: Monospecifi c test using purifi ed GAD.

Cerebellum Pancreas

6 Autoantibodies IIFT pattern Test systems

Anti-ZIC4 IIFT: ANA-like ﬂ uorescence of the neuronal nuclei of the cerebellar stratum granulosum. The cell nuclei of the Autoantibodies against zinc ﬁ nger Purkinje cells are negative in the presence of anti-ZIC4 proteins antibodies, whereas with ANA* all cells are stained. (probably ZIC1, 2 and 4) Antibodies against ZIC4 should be assessed not only on cerebellar sections, but also on transfected cells in Associated disease: cerebellar degeneration parallel.

Associated tumour: small-cell lung carcinoma EUROLINE: Positive reaction of the speciﬁ c target antigen ZIC4. Cerebellum ZIC4 (transf. cells)

Anti-MAG IIFT: Fluorescence of the lamina alba in the cerebellum. Annular ﬂ uorescence on the substrate peripheral nerve. Autoantibodies against myelin- associated glycoprotein, a cell Clinically relevant antibodies are mainly those of class membrane protein of the myelin IgM. sheaths

Associated diseases: paraproteinaemic neuropathy, particularly in the context of monoclonal IgM gammopathy, e.g. monoclonal gammopathy of undetermined signiﬁ cance (MGUS) and Waldenström‘s syndrome Cerebellum Nerve (section)

Anti-myelin IIFT: Fluorescence of the lamina alba in the cerebellum. Fluo rescing hyaline cylinders on the substrate Autoantibodies against myelin and peripheral nerve. myelin proteins (e.g. MBP**) in the myelin sheath of axons

Associated diseases: diagnostic signiﬁ cance is controversial

Cerebellum Nerve (section)

*ANA = anti-nuclear antibodies **MBP = myelin basic protein 7 Autoantibodies IIFT pattern Test systems

Anti-AQP-4 (NMO-IgG) IIFT: Perivascular ﬂ uorescence with linear staining along the Virchow-Robin spaces and the microvessels Autoantibodies against aquaporin-4 in the grey and white matter on the substrate (AQP-4), a water channel of the cerebellum, as well as a reticular ﬂ uorescence on the dystroglycan protein complex Cerebellum substrate optic nerve.

Associated diseases: neuromyelitis optica (NMO, Monospeciﬁ c test using AQP4-transfected HEK cells. opticospinal encephalomyelitis, Devic‘s syndrome), longitudinally extensive transverse myelitis (LETM) and recurrent optic neuritis (rec. ON). NMO, LETM and rec. ON can also occur with systemic lupus erythematosus or Sjögren‘s syndrome Optic nerve AQP-4 (transf. cells)

Anti-MOG (anti-myelin IIFT: The white matter of the cerebellum shows a oligodendrocyte glycoprotein) granular ﬂ uorescence.

Autoantibodies against myelin oligo- Monospeciﬁ c test using MOG-transfected HEK cells. dendrocyte glycoprotein, a cell membrane protein of the myelin sheaths

Associated diseases: neuromyelitis optica (NMO), NMO spectrum disorders (NMOSD), acute disseminated encephalomyelitis (ADEM), clinically isolated syndrome (CIS), multiple sclerosis Cerebellum Associated tumour: – MOG (transf. cells)

Anti-NMDA receptors IIFT: Fluorescence of the stratum moleculare of the hippocampus (neuropil staining) and the stratum Autoantibodies against glutamate granulosum of the cerebellum. receptors (type NMDA*) Cerebellum Monospeciﬁ c test using NMDA receptor (NR1)- Associated disease: anti-glutamate receptor (type transfected HEK cells. NMDA) encephalitis (~ 60 % as paraneoplastic syndrome)

Associated tumours: ovarian teratoma, testicular teratoma

Hippocampus NMDAR (transf. cells)

*NMDA = N-methyl-D-aspartate 8 Autoantibodies IIFT pattern Test systems

Anti-AMPA receptors IIFT: Fluorescence of the stratum moleculare of the hippocampus (neuropil staining), the stratum Autoantibodies against glutamate moleculare and stratum granulosum of the cerebellum receptors (type AMPA*) and the Purkinje cells. Cerebellum Associated disease: limbic encephalitis Monospeciﬁ c test using AMPA1/2-transfected HEK cells. (~ 70 % as paraneoplastic syndrome)

Associated tumours: lung carcinoma, breast carcinoma, malignant thymoma

AMPAR1/R2 Hippocampus (transf. cells)

Anti-GABAB receptors IIFT: Coarse granular fl uorescence of the stratum moleculare of the hippocampus (neuropil staining) Autoantibodies against and the cerebellum. Also patchy fl uorescence of the ** GABAB receptors cerebellar stratum granulosum. Cerebellum Associated disease: limbic encephalitis Monospecifi c test using GABAB receptor-transfected (~ 50 % as paraneoplastic syndrome) HEK cells. Associated tumour: small-cell lung carcinoma

Hippocampus GABABR (transf. cells)

Anti-LGI1 IIFT: Fine granular ﬂ uorescence of the stratum moleculare of the hippocampus (neuropil staining) Autoantibodies against LGI1***, a and the cerebellum. Also patchy ﬂ uorescence of the protein associated with voltage-gated cerebellar stratum granulosum. The outer molecular potassium channels (VGKC) Cerebellum layer of the hippocampus shows a stronger reaction than the inner layer. Associated disease: limbic encephalitis

Associated tumours: thyroid carcinoma, small-cell Monospeciﬁ c test using LGI1-transfected HEK cells. lung carcinoma, kidney cell carcinoma, ovarian teratoma, thymoma

Hippocampus LGI1 (transf. cells)

* ** *** AMPA = α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid GABAB = γ-aminobutyric acid LGI1 = leucine-rich glioma-inactivated protein 1 9 Autoantibodies IIFT pattern Test systems

Anti-CASPR2 IIFT: Fluorescence of the stratum moleculare of the hippocampus (neuropil staining) and the cerebellum. Autoantibodies against CASPR2*, a Also patchy ﬂ uorescence of the cerebellar stratum protein associated with voltage-gated granulosum. potassium channels (VGKC) Cerebellum Monospeciﬁ c test using CASPR2-transfected HEK cells. Associated diseases: limbic encephalitis, neuromyotonia, Morvan‘s syndrome

Associated tumours: thymoma, uterine carcinoma

Hippocampus CASPR2 (transf. cells)

Anti-DPPX IIFT: Positive reaction of the stratum granulosum and stratum moleculare of the cerebellum as well as the Autoantibodies against the regulatory stratum lucidum of the hippocampus. subunit of the voltage-gated potassium channel Kv4.2 ** Cerebellum Monospeciﬁ c test using DPPX -transfected HEK cells. Associated disease: encephalomyelitis

Hippocampus DPPX (transf. cells)

Anti-IgLON5 IIFT: Fluorescence of the stratum moleculare of the hippocampus (neuropil staining) and the cerebellum. In Autoantibodies against a neuronal cell addition, patchy ﬂ uorescence of the cerebellar stratum adhesion protein of the Ig superfamily granulosum. Hippocampus Associated diseases: parasomnia, tauopathy Monospeciﬁ c test using IgLON5-transfected HEK cells.

Cerebellum IgLON5 (transf. cells)

*CASPR2 = contactin-associated protein 2 **DPPX = dipeptidyl aminopeptidase-like protein 6 10 Antibodies and clinical signiﬁ cance Antibodies (synonym) Antigen Sample Syndrome Most frequent tumours (molecular weight) material

Antibodies in diseases of the central nervous system Anti-Hu (ANNA-1) Hu protein (38 kDa) Serum Encephalomyelitis, SCLC, neuroblastoma sensory neuropathy

Anti-Ri (ANNA-2) NOVA (55 kDa and 80 kDa) Serum Opsoclonus myoclonus Breast carcinoma, SCLC syndrome

Anti-Yo (PCA-1) CDR2, CDR62 (34 kDa and Serum Cerebellar degeneration Ovarian, breast and uterine 62 kDa) carcinoma

P CA-2 Purkinje cell protein (280 kDa) Serum Encephalitis, SCLC neuropathy

Anti-PNMA1 (Ma1) Ma protein (37 kDa) Serum Rhombencephalitis (brain Breast carcinoma, various stem), limbic encephalitis tumours

Anti-PNMA2 (Ma2/Ta) Ma protein (40 kDa) Serum Rhombencephalitis (brain Testicular carcinoma stem), limbic encephalitis

Anti-Tr (DNER) Purkinje cell protein Serum Cerebellar degeneration Hodgkin‘s lymphoma

Anti-ITPR1 (Anti-Sj) Inositol 1,4,5 trisphosphate Serum Cerebellar ataxia NSCLC in an unpublished case receptor 1 (300 kDa)

Anti-CARP CARP VIII; carbonic anhydrase-Serum Paraneoplastic cerebellar Melanoma, ovarian carcinoma related protein VIII (29 kDa) de generation, cerebellar ataxia

Anti-amphiphysin Amphiphysin (128 kDa) Serum Stiff-person syndrome Breast carcinoma, SCLC

SCLC: small-cell lung carcinoma

11 Antibodies (synonym) Antigen Sample Syndrome Most frequent tumours (molecular weight) material

Anti- CV2 66 kDa protein Serum Limbic encephalitis SCLC, thymoma

Anti-SOX1 Sry-like high mobility group Serum LEMS, cerebellar degeneration, SCLC box protein 1 (39 kDa) sensory neuropathy

Anti-ZIC4 Zinc ﬁ nger protein ZIC4 Serum Cerebellar degeneration SCLC (36 kDa)

Anti-recoverin Recoverin (23 kDa) Serum Retinopathy SCLC

Anti-GAD Glutamic acid decarboxylase Serum Stiff-person syndrome Breast carcinoma, SCLC, colon (65 kDa and 67 kDa) CSF carcinoma

Anti-glia nuclear SOX1 protein Serum LEMS, cerebellar degeneration SCLC antibodies (AGNA)

Anti-AQP-4 (NMO IgG) Aquaporin-4 protein Serum Neuromyelitis optica (NMO), – LETM , rec. ON

Anti-MOG Myelin oligodendrocyte Serum NMO / NMOSD, ADEM, CIS, MS – glycoprotein (28 kDa)

Anti-NMDA receptors Extracellular domain of the Serum Anti-glutamate receptor (type Teratoma (ovary, testis) NR1 subunit of the receptor CSF NMDA) encephalitis

Anti-AMPA receptors GluR1 and GluR2 subunits of Serum Limbic encephalitis Breast carcinoma, thymoma, the receptor (each approx. CSF lung carcinoma 100 kDa)

LEMS: paraneoplastic Lambert-Eaton myasthenic syndrome LETM:longitudinally extensive transverse myelitis rec. ON: recurrent optic neuritis ADEM: acute disseminated encephalomyelitis

12 Antibodies (synonym) Antigen Sample Syndrome Most frequent tumours (molecular weight) material

Anti-m GluR1 Metabotropic glutamate Serum Cerebellar degeneration Hodgkin‘s lymphoma receptor (approx. 140 kDa) CSF

Anti-mGluR5 Metabotropic glutamate Serum Ophelia syndrome Hodgkin‘s lymphoma receptor (132 kDa) CSF

Anti-GABAB receptors Extracellular domain of Serum Limbic encephalitis SCLC

the GABAB subunit of the CSF receptor

Anti-LGI1 Protein (60 kDa) associated Serum Limbic encephalitis SCLC, ovarian teratoma, with voltage-gated potassium CSF thy moma, various tumours channels (VGKC)

Anti-CA SPR2 Protein associated with Serum Limbic encephalitis, Thymoma, uterine carcinoma voltage-gated potassium CSF neuromyotonia, Morvan‘s channels (VGKC) syndrome

Anti-DPPX Dipeptidyl aminopeptidase- Serum Encephaltis, encephalomyelitis – like protein 6 (98 kDa) CSF

Anti-IgLON5 Cell adhesion protein of the Serum Parasomnia, tauopathy – Ig superfamily (37 kDa) CSF

Anti-GlyR Glycine receptor alpha 1 Serum PERM, stiff-person syndrome, Thymoma, Hodgkin‘s (53 kDa) CSF hyperekplexia lymphoma

PERM: progressive encephalomyelitis with rigidity and myoclonus

13 Antibodies (synonym) Antigen Sample Syndrome Most frequent tumours (molecular weight) material

Antibodies in diseases of the peripheral nervous system Anti-GQ1b Tetrasialoganglioside GQ1b Serum Miller-Fisher syndrome –

Anti-GM1 Monosialoganglioside GM1 Serum Multifocal motor neuropathy, – Guillain-Barré syndrome

Anti-myelin Myelin Serum Diagnostic value controversial –

Anti-MAG Myelin-associated Serum Guillain-Barré syndrome – glycoprotein (100 kDa)

Antibodies in neuromuscular diseases Anti-A ChR Acetylcholine receptor of Serum Myasthenia gravis Thymoma the muscular end plate (α1: 55 KDa) Anti-titin Titin (3816 kDa) Serum Myasthenia gravis Thymoma

Anti-MusK Receptor tyrosine kinase, Serum Myasthenia gravis Thymoma skeletal muscle speciﬁ c (97 kDa)

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EUROIMMUN AG · Seekamp 31 · 23560 Lübeck (Germany) · Tel +49 451/5855-0 · Fax 5855-591 · [email protected] · www.euroimmun.com