Autoimmune processes in neurological patients are much more common than presently suspected.

Autoimmune encephalitides are seldom diseases. How rare they actually are, however, is not known. The low incidence combined with the problematic identification may dampen efforts of neurologists, to identify patients with unclear symptoms as suffering from autoimmune encephalitis. Here, we aim to obtain a better estimate, how many patients with autoimmune disorders should be expected among 100 inpatients in a conventional neurological department. From a total number of 2603 non-stroke patients attended in a 2-year period (2018-2019) 460 CSFs were obtained. From this collection 187 samples (40.7%, > 500 sections) could be analyzed with our immunocytochemical technique. Autoreactive antibodies were detected in 102 (55%) of these 187 CSF samples. Certainly, the presence of autoreactive antibodies does not necessarily indicate that the patient suffers from an autoimmune disease. Our data indicate that from roughly 2000 patients during 1 year about 125 patients with autoreactive CSF antibodies should be expected in a conventional neurological department. This represents the about 35-fold value of what is generally expected at present. Being aware of this high incidence may intensify the efforts of neurologist to identify patients with any type of autoimmune encephalitis. This will be beneficial for patients, because they often profit from immunomodulatory therapy. Interestingly, some CFSs from our patients react with the CA2 subdivision of the hippocampus. While long neglected, recent research places this area into an important position to influence hippocampal network physiology. Autoreactive antibodies in the CSF may disturb the function of CA2 neurons, thereby explaining some neuropsychiatric symptoms in patients with autoimmune encephalitides.

Detailed morphological analysis of rat hippocampi treated with CSF autoantibodies from patients with anti-NMDAR encephalitis discloses two distinct types of immunostaining patterns.

Anti-NMDA receptor encephalitis was first described about thirteen years ago and has become one of the most important differential diagnoses for new-onset psychosis. The disease is mediated by autoantibodies against the subunit 1 of the N-methyl-D-aspartate receptor (NMDA-R1) in patients presenting with variable clinical symptoms. Patients often profit from immunmodulatory therapy, independent of their individual symptoms. In this study CSF samples as well as monoclonal antibodies derived from patients diagnosed with NMDA-R1 encephalitis were applied to rat hippocampus and visualized by immunocytochemistry. This reveals at least two distinct patterns of immunoreactivity. Antibodies from "pattern group 1" display the familiar pattern of NMDA-R1 distribution in the hippocampus reported in experiments with rabbit anti-NMDA-R1 antibodies. Neurons and primary dendrites in the CA1 and CA3 region show strongly stained cell bodies, in line with the predominant postsynaptic localization of the NMDA receptor in the brain. However, autoantibodies from "pattern group 2" show an inverse pattern, with no staining of the cell bodies and primary dendrites in CA1 and CA3 regions. Electron microscopic experiments disclose that autoantibodies of "pattern group 1 patients" bind to postsynaptic NMDA receptors, while those of "pattern group 2 patients" target presynaptic NMDA receptors. We describe one NMDA-receptor antibody giving staining comparable to rabbit anti-NMDA-R1 antibodies, raised against the C-terminus. In the highly heterogenous disease anti-NMDA-receptor 1 encephalitis we found evidence for at least two different subtypes. It will be very interesting to determine whether there also are two distinct clinical phenotypes.

Fañanas cells-the forgotten cerebellar glia cell type: Immunocytochemistry reveals two potassium channel-related polypeptides, Kv2.2 and Calsenilin (KChIP3) as potential marker proteins.

For long times astrocytes had been regarded as supporting cells, passively filling the spaces between neuronal cell bodies and their extensions. Now it is known that astrocytes are actively involved in a variety of important biological functions such as regulating cerebral blood flow, supporting neuronal metabolism, controlling the extracellular potassium concentration, and clearing neurotransmitters from the extracellular space. In line with this multitude of tasks astrocytes display conspicuous functional and regional heterogeneity. Using three complementary labeling methods nine classes of astrocytes have been differentiated, which were termed protoplasmic, fibrous, velate, radial, and perivascular astrocytes in addition to Bergmann, marginal, and ependymal glial cells. To complete this list retinal Müller cells and a largely forgotten astrocytic cell type, the "feathered cell" of Fañanas need to be added. So far, Fañanas cells could be only recognized with the tedious gold-sublimate procedure. Consequently, data indicating a potential biological function are completely missing. In a parallel investigation we used a battery of antibodies against potassium channels and related proteins to identify potential marker proteins for the immunocytochemical visualization of distinct cell types in the cerebellar cortex. Here we present novel marker proteins, the Kv2.2 potassium channel and calsenilin, to visualize Fañanas cells in the cerebellar Purkinje cell layer. Such markers will allow to identify Fañanas cell subsequent to patching and electrophysiological characterization. This may pave the path to obtain new functional data, which may be helpful to understand the role of these enigmatic cells in normal biological function and disease.

Posterior Reversible Encephalopathy Syndrome due to Hypomagnesemia: A Case Report and Literature Review.

BACKGROUND: Hypomagnesemia can cause various unspecific neurological complications, which can lead to diagnostic confusion. One of these complications is the posterior reversible encephalopathy syndrome (PRES), which is extremely uncommon and has been reported only twice in the English-language literature. CASE PRESENTATION: We report the case of a 60-year-old man who presented with PRES involving only the cerebellar hemispheres and associated with hypomagnesemia. After excluding all the other possible etiologies of PRES, we started magnesium replacement therapy, which led to a remarkable but fluctuating clinical and chemical improvement. A full recovery with no need for further supplementation was achieved only after discontinuation of a proton pump inhibitor. CONCLUSIONS: This case highlights the role of magnesium in the pathophysiology of PRES; thereby, underlying hypomagnesemia should be considered in every PRES case with unclear etiology.

Stroke as an Unusual First Presentation of Lyme Disease.

Introduction. Lyme neuroborreliosis is a nervous system infection caused by spirochete Borrelia burgdorferi with diverse neurological complications. Stroke due to cerebral vasculitis is a rare consequence of neuroborreliosis and has been described in just a few case reports. Case Presentation. Here, we report the case of a 43-year-old patient who presented with discrete left-sided hemiparesis and amnestic cognitive impairment. Brain magnetic resonance imaging showed a thalamic infarct, and serological and cerebrospinal fluid (CSF) tests confirmed the diagnosis of active neuroborreliosis. The antibiotic treatment with intravenous ceftriaxone for three weeks led to an improvement of the symptoms and remarkable regression of radiological findings, but not to full recovery of the amnestic cognitive disorder. Conclusion. Lyme neuroborreliosis should be suspected in patients with cerebrovascular events without obvious risk factors, especially those living in endemic areas such as northern Europe or those who have been exposed to ticks and those with clinical or radiological findings suggesting Lyme neuroborreliosis, in order to establish the diagnosis and start a proper antibiotic therapy.