Immunotherapy in selected patients with Down syndrome disintegrative disorder.

Down syndrome disintegrative disorder (DSDD) is an increasingly identified condition characterized by cognitive decline, autistic characteristics, insomnia, catatonia, and psychosis in adolescents and young adults with Down syndrome. Previously we reported a higher rate of autoimmune thyroid disease in these patients compared with unaffected individuals with Down syndrome. We therefore hypothesized DSDD may in some cases be immune-mediated. Here we report four cases of DSDD treated with immunotherapy. Families were interviewed retrospectively for symptoms of cognitive decline, autism, catatonia, psychosis, and insomnia before and after treatment, using established scales where possible. Medical records were reviewed for evaluations and treatment. All four patients received intravenous immunoglobulin with or without additional immunotherapy. Significant improvements were seen in catatonia, insomnia, autistic features, cognition, and psychosis. In this small case series of patients with autoimmunity, core symptoms of DSDD improved significantly after immunotherapy. This supports the hypothesis that, in some patients, DSDD is immune-mediated. Immunotherapy should be considered in the treatment of DSDD, particularly in patients with a history of autoimmunity. WHAT THIS PAPER ADDS: Immunotherapy may improve symptoms of catatonia, insomnia, autism severity, cognitive decline, and psychosis in Down syndrome disintegrative disorder.

INMUNOTERAPIA EN PACIENTES SELECCIONADOS CON TRASTORNO DESINTEGRATIVO DEL SÍNDROME DE DOWN: El trastorno desintegrativo del síndrome de Down (TDSD) es una afección cada vez más identificada que se caracteriza por deterioro cognitivo, características autistas, insomnio, catatonia y psicosis en adolescentes y adultos jóvenes con síndrome de Down. Anteriormente informamos una tasa más alta de enfermedad tiroidea autoinmune en estos pacientes en comparación con las personas no afectadas con síndrome de Down. Por lo tanto, hipotetizamos que el TDSD puede, en algunos casos, estar inmunomediado. Aquí presentamos cuatro casos de TDSD tratados con inmunoterapia. Las familias fueron entrevistadas retrospectivamente para los síntomas de deterioro cognitivo, autismo, catatonía, psicosis e insomnio antes y después del tratamiento, utilizando escalas establecidas cuando sea posible. Los registros médicos fueron revisados ​​para evaluaciones y tratamiento. Los cuatro pacientes recibieron inmunoglobulina intravenosa con o sin inmunoterapia adicional. Se observaron mejoras significativas en catatonia, insomnio, características autistas, cognición y psicosis. En esta pequeña serie de casos de pacientes con autoinmunidad, los síntomas centrales de la TDSD mejoraron significativamente después de la inmunoterapia. Esto apoya la hipótesis de que, en algunos pacientes, la TDSD está inmunomediada. La inmunoterapia debe considerarse en el tratamiento de la TDSD, particularmente en pacientes con antecedentes de autoinmunidad.

IMUNOTERAPIA EM PACIENTES SELECIONADOS COM SÍNDROME DE DOWN E TRANSTORNO DESINTEGRATIVO: O transtorno desintegrativo na síndrome de Down (TDSD) é uma condição crescentemente identificada, caracterizada por declínio cognitivo, características autistas, insônia, catatonia, e psicose em adolescente e jovens adultos com síndrome de Down. Nós relatamos previamente uma taxa maior de doença autoimune da tireóide nestes pacientes comparados com indivíduos com síndrome de Down não afetados. Portanto, hipotetizamos que o TDSD pode, em alguns casos, ser imune-mediado. Aqui reportamos quatro casos de TDSD tratados com imunoterapia. As famílias foram entrevistadas retrospectivamente quanto a sintomas de declínio cognitivo, autismo, catatonia, psicose, e insônia antes e depois do tratamento, usando escalas estabelecidas quando possível. Os registros médicos foram revisados quanto a avaliações e tratamento. Todos os quatro pacientes receberam imunoglobulina intravenosa com ou sem imunoterapia adicional. Melhoras significativas foram vistas na catatonia, aspectos autistas, cognição, e psicose. Nesta pequena série de casos de pacientes com auto-imunidade, os sintomas centrais de TDSD melhoraram significativament após imunoterapia. Isso apóia a hipótese de que, em alguns pacientes, o TDSD é imuno-mediado. A imunoterapia deve ser considerada no tratamento do TDSD, particularmente em pacientes com história de autoimunidade.

Acetylcholinesterase inhibition ameliorates deficits in motivational drive.

BACKGROUND: Apathy is frequently observed in numerous neurological disorders, including Alzheimer's and Parkinson's, as well as neuropsychiatric disorders including schizophrenia. Apathy is defined as a lack of motivation characterized by diminished goal-oriented behavior and self-initiated activity. This study evaluated a chronic restraint stress (CRS) protocol in modeling apathetic behavior, and determined whether administration of an anticholinesterase had utility in attenuating CRS-induced phenotypes. METHODS: We assessed behavior as well as regional neuronal activity patterns using FosB immunohistochemistry after exposure to CRS for 6 h/d for a minimum of 21 d. Based on our FosB findings and recent clinical trials, we administered an anticholinesterase to evaluate attenuation of CRS-induced phenotypes. RESULTS: CRS resulted in behaviors that reflect motivational loss and diminished emotional responsiveness. CRS-exposed mice showed differences in FosB accumulation, including changes in the cholinergic basal forebrain system. Facilitating cholinergic signaling ameliorated CRS-induced deficits in initiation and motivational drive and rescued immediate early gene activation in the medial septum and nucleus accumbens. CONCLUSIONS: Some CRS protocols may be useful for studying deficits in motivation and apathetic behavior. Amelioration of CRS-induced behaviors with an anticholinesterase supports a role for the cholinergic system in remediation of deficits in motivational drive.

Assessment and Diagnosis of Down Syndrome Regression Disorder: International Expert Consensus.

Objective: To develop standardization for nomenclature, diagnostic work up and diagnostic criteria for cases of neurocognitive regression in Down syndrome. Background: There are no consensus criteria for the evaluation or diagnosis of neurocognitive regression in persons with Down syndrome. As such, previously published data on this condition is relegated to smaller case series with heterogenous data sets. Lack of standardized assessment tools has slowed research in this clinical area. Methods: The authors performed a two-round traditional Delphi method survey of an international group of clinicians with experience in treating Down syndrome to develop a standardized approach to clinical care and research in this area. Thirty-eight potential panelists who had either previously published on neurocognitive regression in Down syndrome or were involved in national or international working groups on this condition were invited to participate. In total, 27 panelists (71%) represented nine medical specialties and six different countries reached agreement on preliminary standards in this disease area. Moderators developed a proposed nomenclature, diagnostic work up and diagnostic criteria based on previously published reports of regression in persons with Down syndrome. Results: During the first round of survey, agreement on nomenclature for the condition was reached with 78% of panelists agreeing to use the term Down Syndrome Regression Disorder (DSRD). Agreement on diagnostic work up and diagnostic criteria was not reach on the first round due to low agreement amongst panelists with regards to the need for neurodiagnostic testing. Following incorporation of panelist feedback, diagnostic criteria were agreed upon (96% agreement on neuroimaging, 100% agreement on bloodwork, 88% agreement on lumbar puncture, 100% agreement on urine studies, and 96% agreement on "other" studies) as were diagnostic criteria (96% agreement). Conclusions: The authors present international consensus agreement on the nomenclature, diagnostic work up, and diagnostic criteria for DSRD, providing an initial practical framework that can advance both research and clinical practices for this condition.