CLINICAL/SCIENTIFIC NOTES OPEN ACCESS Antibodies to nodal/paranodal proteins in paediatric immune-mediated neuropathy Desiree De Simoni, MD, Gerda Ricken, MSc, Michael Winklehner, MD, Inga Koneczny, PhD, Correspondence Dr. Rostásy Michael Karenfort, MD, Ulf Hustedt, MD, Ulrich Seidel, MD, Omar Abdel-Mannan, MD, Pinki Munot, MD, k.rostasy@kinderklinik-datteln.de Simon Rinaldi, MD, Claudia Steen, MD, Michael Freilinger, MD, Markus Breu, MD, Rainer Seidl, MD, or Dr. Höftberger Markus Reindl, PhD, Julia Wanschitz, MD, Cinta Lleixà, PhD, Günther Bernert, MD, romana.hoeftberger@ Klaus-Peter Wandinger, MD, PhD, Ralf Junker, MD, Luis Querol, MD, PhD, Frank Leypoldt, MD, PhD, meduniwien.ac.at Kevin Rostásy, MD,* and Romana Höftberger, MD* Neurol Neuroimmunol Neuroinflamm 2020;7:e763. doi:10.1212/NXI.0000000000000763 Patients with nodal/paranodal antibodies represent a specific subgroup of inflammatory pe- ripheral neuropathies, whose clinical presentation with a prolonged subacute phase, additional symptoms such as ataxia and tremor, and poor treatment response to IV immunoglobulin (IVIG) often differs from classic Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP).1 Previous studies on nodo/paranodopathies mainly focused on adult patients, whereas the clinical spectrum of pediatric patients is less well established. We reviewed the clinical pre- sentation of 54 children with GBS (n = 42) and CIDP (n = 12) and retrospectively screened for antibodies against neurofascin155 (NF155), NF186, NF140, contactin-1 (CNTN1), contactin- associated protein1 (CASPR1), and glycine-receptor (GlyR) using cell-based assays2,3; 1 pa- tient was additionally tested with CNTN1-ELISA.4 All cases with sufficient serum were tested for ganglioside-IgG-, IgA-, and IgM-antibodies against GM1 (n = 42), GD1a (n = 18), GD1b (n = 23), and GQ1b (n = 21).5 Clinical and paraclinical information of all patients is summarized in the table. The study was approved by the ethics committee (EK1773/2016). Children with classic GBS Of 42 children with GBS, 26 were classified as acute inflammatory demyelinating poly- neuropathy (AIDP), 7 as acute motor/motor-sensory axonal neuropathy (AMAN/AMSAN) by nerve conduction velocity according to Hadden criteria,6 4 as Miller-Fisher syndrome (MFS), and 2 as MFS/GBS overlap. Three patients with GBS could not be classified because of lack of nerve-conduction studies. In 25 of 35 patients (71.4%), an infection was reported within 4 weeks before symptom onset (13 gastrointestinal, 4 respiratory, and 8 unspecified). Eight patients had IgG-ganglioside antibodies (19.0%), 6 IgM (14.2%), and 1 IgA (2.4%). Nodal/ paranodal antibodies were not detected. Patients with AMAN/AMSAN (5/7 with reported infection: 1 campylobacter jejuni, 1 varicella-zoster virus, and 3 unspecified) were more often ganglioside antibody positive (6/7) than patients with AIDP (4/26; likelihood ratio 12.419) or MFS (2/4). *These authors contributed equally to this work. From the Division of Neuropathology and Neurochemistry (D.D.S., G.R., M.W., I.K., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (D.D.S.), University Hospital St. Poelten, Austria; Department of General Pediatrics, Neonatology and Pediatric Cardiology (M.K.), University Children’s Hospital, Heinrich Heine University Duesseldorf, Germany; Department of Neuropediatric Rehabilitation (U.H.), Vamed Clinic Hattingen, Germany; Department of Neuropediatrics (U.S.), Charité University, Berlin, Germany; Paediatric Neurology (O.A.-M.), Great Ormond Street Hospital for Children, London, United Kingdom; Dubowitz Neuromuscular Centre (P.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Nuffield Department of Clinical Neurosciences (S.R.), University of Oxford and Oxford University Hospitals NHS Foundation Trust; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin, Germany; Department of Pediatrics and Adolescent Medicine (M.F., M.B., R.S.), Medical University of Vienna, Austria; Department of Neurology (M.R., J.W.), Medical University of Innsbruck, Austria; Neuromuscular Diseases Unit (C.L., L.Q.), Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Spain; SMZ Süd (G.B.), Kaiser-Franz Josef Hospital with Gottfried von Preyer Children Hospital, Vienna, Austria; Institute of Clinical Chemistry (K.- P.W., R.J., F.L.), University Hospital Schleswig-Holstein, Kiel/Lübeck, Germany; Department of Neurology (F.L.), University Hospital Schleswig-Holstein, Kiel, Germany; and Department of Pediatric Neurology (K.R.), Witten/Herdecke University, Children’s Hospital Datteln, Germany. Go to Neurology.org/NN for full disclosures. Funding information is provided at the end of the article. The Article Processing Charge was funded by Austrian Science Fund. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. 1 Table Clinical and paraclinical data of patients with GBS and CIDP GBS (42) CIDP (12) Ganglioside abs pos. Nodal/paranodal (IgG/IgM/IgA) Seronegative antibodies pos. Seronegative No. of patients 15 27 5 7 Age mean (range) 11.6 (4–17) 10.22 (1–18) 7.9 (3–11) 10.4 (4–18) Gender m:f 9:6 15:12 3:2 4:3 AIDP 4 22 AMAN/AMSAN 6 1 MFS/MFS overlap 3/1 1/1 GBS no NCS 1 2 GM1+ 6 — 0 0 GD1a+ 1 0 0 GD1b+ 1 0 0 GM1+GD1b+ 4 0 0 GQ1b+ 1 0 0 GM1+GD1a+ GQ1b+ 1 GD1a+GQ1b+ 1 Pan-neurofascin+ — — 2 0 NF155+ 1 0 CNTN1+ 2 0 CSF mean cell count/μL (range) 3.15 (0–11) 2.92 (0–11) 4.6 (0–21) 3.8 (1–9) CSF mean total protein mg/dL (range) 98.08 (10–250) 118.59 (19–401) 292.4 (75–619) 107.7 (24–288) Infection (data available from 45/54) 11 (2 C. jejuni; 1 VZV; 8 14 (2 C. jejuni; 3 VZV; 1 EBV; 8 1 2 unspecified) unspecified) GI 6 7 1 0 Respiratory 2 2 0 2 Other 3 5 0 0 Infection d prior mean (range) 9 (1–14) 11.6 (3–28) 0 4.8 (1–10) Days hospitalization mean (range) 13.43 (3–30) 20.73 (0–135) 13 (2–28) 10.4 (2–16) Cranial nerve involvement 3 7 1 2 Autonomic dysfunction 1 2 0 0 Tremor/ataxia 3 3 5 1 Outcome mRS (available from 32/42 GBS 11 mRS 0–1; 1 mRS 2–4; 15 mRS 0–1; 4 mRS 2–4; 1 mRS 2 mRS 0–1; 3 mRS 2–4; 2 mRS 0–1; 4 mRS and 11/12 CIDP) 1 mRS >1; 5–6; 5 mRS >1; 3 mRS >1; 2–4; 4 mRS >1; Severity at nadir HS (available from 41/ 2 HS1; 8 HS2; 1 HS3; 2 2 HS1; 5 HS2; 7 HS3; 6 HS4; 6 3 HS3; 2 HS4 2 HS1; 1 HS2; 4 HS4 42 GBS and 12/12 CIDP) HS4; 1 HS5 HS5; 1 HS6 Abbreviations: AIDP = acute inflammatory demyelinating polyneuropathy; AMAN = acute motor axonal neuropathy; AMSAN = acute motor and sensory axonal neuropathy; C. jejuni = campylobacter jejuni; CIDP = chronic inflammatory demyelinating polyneuropathy; EBV = Epstein-Barr virus; GBS = Guillain- Barré syndrome; GI = gastrointestinal; HS = Hughes score; MFS = Miller-Fisher syndrome; mRS = modified Rankin Scale; NCS = nerve-conduction study; VZV = varicella-zoster-virus. 2 Neurology: Neuroimmunology & Neuroinflammation | Volume 7, Number 4 | July 2020 Neurology.org/NN Children with nodal/ do not sufficiently respond to IVIG, whereas in our case series, rituximab led to prompt improvement in 3 children. Optimal paranodal antibodies treatment strategies for children with nodal/paranodal anti- Five of 12 children, who met the EFNS/PNS criteria for CIDP, bodies have to be further determined in larger studies. had nodal/paranodal antibodies: 2 pan-neurofascin (NF155/ NF186/140 triple positive), 1 NF155, and 2 CNTN1- Acknowledgment antibodies. The IgG-subclass distribution was determined by The authors thank Valerie Pichler and Sopie Dürauer for flow cytometry analysis.7 IgG4 was the predominant subclass in technical assistance and Andreas Spittler from the Flow all patients and ranged from 75% to 100%. In addition, 1 patient Cytometry Core facility of the MUV for technical support. with pan-neurofascin-antibodies tested positive for GlyR- Study funding antibodies but did not develop stiff-person syndrome or pro- gressive encephalomyelitis with rigidity, and the significance of This work was partly supported by grants from the this finding needs further investigation. The mean age was 7.9 “Jubiläumsfonds der Österreichischen Nationalbank,” project 16919 (R. Höftberger), the GBS/CIDP Foundation International years (range 3–11), and the male:female ratio was 3:2. The median duration of hospitalization was 13 days (range 2–28). (J. Wanschitz), Austrian Science Fund FWF, DOC 33-B27 One pan-neurofascin-patient was initially diagnosed as GBS and (R. Höftberger, M. Winklehner) and I3334-B27 (R. Höftberger), Hertha Firnberg project number T996-B30 (I. Koneczny), reclassified as CIDP during disease course, the other patients had a chronic onset with slow progression over months or years. the PI16/000627 grant of the Fondo de Investigaciones One child had a gastrointestinal infection before symptom Sanitarias—Instituto de Salud Carlos III (fondos FEDER) (L. Querol), personal grant SLT006/17/00131 of the Pla onset. One CNTN1-patient showed cranial nerve involvement and optic neuritis during disease course. All children had ataxia, estratègic de Recerca i Innovació en Salut (PERIS), Departament 4 neuropathic pain (all except 1 pan-neurofascin), and 3 (2 de Salut, Generalitat de Catalunya (L. Querol), and the German Ministry of Education and Research (BMBF, 01 GM1908A). CNTN1, and 1 pan-neurofascin) tremor. At the peak of disease, 3 children needed a walking aid (Hughes 3) and 2 were bed- ridden (Hughes 4). None of the children had renal dysfunction. Disclosure D. De Simoni, G. Ricken, M. Winklehner, I. Koneczny, The mean CSF white cell count was 4.6 μL (range 0–21), and the mean CSF protein was 292.4 mg/dL (range 75–619). M. Karenfort, U. Hustedt, U. Seidel, O. Abdel-Mannan, P. Munot, S. Rinaldi, C. Steen, M. Freilinger, M. Breu, R. Seidl, M. Reindl, J. Wanschitz, C. Lleixá, G. Bernert, The mean time of follow-up was 32 months (range 17–57). The 2 CIDP patients with pan-neurofascin-antibodies initially K.P. Wandinger, R. Junker, L. Querol, F. Leypoldt, K. Rostásy, showed no or only partial response to IVIG and therefore and R. Höftberger report no disclosures relevant to the manuscript. Go to Neurology.org/NN for full disclosures. received corticosteroids, 1 along with plasma exchange and the other with mycophenolate. Both recovered only very slowly over up to 4 years with a modified Rankin Scale (mRS) score of Publication history Received by Neurology: Neuroimmunology & Neuroinflammation 1 at the last follow-up. The NF155-patient did not respond to March 8, 2020. Accepted in final form April 29, 2020. IVIG and corticosteroids and subsequently received immu- noadsorption and rituximab, leading to significant clinical im- provement. After 8 months, he relapsed in association with Appendix Authors normalization of the CD19/20 ratio and again rapidly im- proved after another dose of rituximab, with a mRS score of 2 at Name Location Contribution the last follow-up. One patient with CNTN1-antibodies Desiree De Medical University of Acquisition of data, worsened despite monthly IVIG and corticosteroids given Simoni, MD Vienna, Austria; University statistical analysis, over 4 months. After treatment was switched to rituximab, he Hospital St. Poelten, execution, and Austria interpretation of data improved rapidly in the following weeks and remained stable since then. The second child with CNTN1-antibodies showed Gerda Medical University of Acquisition of data, Ricken, MSc Vienna, Austria execution, interpretation only partial response to IVIG with relapses in conjunction with of data, and critical review infections. This child improved significantly after rituximab for important intellectual content application with a mRS score of 2 at the last follow-up. Michael Medical University of Statistical analysis and Winklehner, Vienna, Austria critical review for In summary, our study demonstrates that nodal/paranodal MD important intellectual antibodies occur in a subgroup of paediatric patients with content CIDP, but not GBS. Children with AMAN/AMSAN fre- Inga Medical University of Acquisition of data, quently have ganglioside antibodies. Children with CIDP and Koneczny, Vienna, Austria execution, interpretation PhD of data, and critical review atypical/prolonged disease course with high Hughes score for important intellectual (>2), sensory ataxia, prominent neuropathic pain, and tremor content may have nodal/paranodal antibodies. These patients often Continued Neurology.org/NN Neurology: Neuroimmunology & Neuroinflammation | Volume 7, Number 4 | July 2020 3 Appendix (continued) Appendix (continued) Name Location Contribution Name Location Contribution Michael University Children’s Acquisition of data and Günther Kaiser-Franz Josef Hospital Acquisition of data and Karenfort, Hospital, Heinrich Heine critical review for Bernert, MD with Gottfried von Preyer critical review for MD University Duesseldorf, important intellectual children Hospital, Vienna, important intellectual Germany content Austria content Ulf Hustedt, Vamed Clinic Hattingen, Acquisition of data and Klaus-Peter University Hospital Acquisition of data and MD Germany critical review for Wandinger, Schleswig-Holstein, Kiel/ critical review for important intellectual MD, PhD Lübeck, Germany important intellectual content content Ulrich Charité University, Berlin, Acquisition of data and Ralf Junker, University Hospital Acquisition of data and Seidel, MD Germany critical review for MD Schleswig-Holstein, Kiel/ critical review for important intellectual Lübeck, Germany important intellectual content content Omar Abdel- Great Ormond Street Acquisition of data and Luis Querol, Hospital de la Santa Creu i Acquisition of data, Mannan, MD Hospital for Children, critical review for MD, PhD Sant Pau, Universitat execution, interpretation London, United Kingdom important intellectual Autónoma de Barcelona, of data, and critical review content Barcelona, Spain for important intellectual content Pinki Munot, Great Ormond Street Acquisition of data and MD Hospital for Children, critical review for Frank University Hospital Conception and design, London, United Kingdom important intellectual Leypoldt, Schleswig-Holstein, Kiel/ acquisition of data, content MD, PhD Lübeck, Germany execution, interpretation of data, and critical review Simon University of Oxford and Acquisition of data and for important intellectual Rinaldi, MD Oxford University critical review for content Hospitals NHS Foundation important intellectual Trust content Kevin Witten/Herdecke Conception and design, Rostásy, MD University, Children’s acquisition of data, Claudia St Joseph Hospital, Berlin, Acquisition of data and Hospital Datteln, Germany statistical analysis, Steen, MD Germany critical review for execution, interpretation important intellectual of data, and critical review content for important intellectual content Michael Medical University of Acquisition of data and Freilinger, Vienna, Austria critical review for Romana Medical University of Conception and design, MD important intellectual Höftberger, Vienna, Austria acquisition of data, content MD execution, interpretation of data, and critical review Markus Medical University of Acquisition of data and for important intellectual Breu, MD Vienna, Austria critical review for content important intellectual content Rainer Seidl, Medical University of Acquisition of data and MD Vienna, Austria critical review for References important intellectual 1. Querol L, Devaux J, Rojas-Garcia R, Illa I. Autoantibodies in chronic inflammatory content neuropathies: diagnostic and therapeutic implications. Nat Rev Neurol 2017;13: 533–547. Markus Medical University of Acquisition of data, 2. Martin-Aguilar L, Pascual-Goni E, Lleixa C, et al. Antibodies against nodo-paranodal Reindl, PhD Innsbruck, Austria interpretation of data, and proteins are not present in genetic neuropathies. Neurology Epub 2020 Feb 26. critical review for 3. Martinez-Hernandez E, Sepulveda M, Rostásy K, et al. Antibodies to aquaporin 4, important intellectual myelin-oligodendrocyte glycoprotein, and the glycine receptor α1 subunit in patients content with isolated optic neuritis. JAMA Neurol 2015;72:187. 4. Mathey EK, Garg N, Park SB, et al. Autoantibody responses to nodal and para- Julia Medical University of Acquisition of data and nodal antigens in chronic inflammatory neuropathies. J Neuroimmunol 2017;309: Wanschitz, Innsbruck, Austria critical review for 41–46. MD important intellectual 5. Yuki N, Tagawa Y, Irie F, et al. Close association of Guillain–Barré syndrome with content antibodies to minor monosialogangliosides GM1b and GM1α. J Neuroimmunol 1997;74:30–34. Cinta Lleixà, Hospital de la Santa Creu i Acquisition of data and 6. Hadden R, Cornblath D, Hughes R, et al. Electrophysiological classification of PhD Sant Pau, Universitat interpretation of data Guillain-Barré syndrome: clinical associations and outcome. Ann Neurol 1998;44: Autónoma de Barcelona, 780–788. Barcelona, Spain 7. Ogata H, Yamasaki R, Hiwatashi A, et al. Characterization of IgG4 anti-neurofascin 155 antibody-positive polyneuropathy. Ann Clin Transl Neurol 2015;2:960–971. 4 Neurology: Neuroimmunology & Neuroinflammation | Volume 7, Number 4 | July 2020 Neurology.org/NN