Epilepsy Associated With Systemic Autoimmune Diseases

Transcription

1 Epilepsy Associated With Systemic Autoimmune Diseases December 5, 2010 Orrin Devinsky, M.D. NYU Langone School of Medicine New York, NY American Epilepsy Society Annual Meeting

2 Disclosure Nothing to disclose. American Epilepsy Society Annual Meeting

3 Systemic Autoimmune Disorders Associated with Epilepsy Systemic lupus erythamatosus Sjogren s syndrome Wegener s granulomatosis & polyarteritis nodosa Crohn s disease Sarcoidosis Behçet s Hashimoto s encephalopathy CNS disorders Primary angiitis of the CNS Multiple sclerosis

4 Mechanisms of Seizures in Systemic Vascular disease Autoimmune Disorders Platelet fibrin thrombi (e.g., TTP) Anticardiolipin antibody & prothrombotic state Emboli Vasculitis Antineuronal antibodies Immune complexes Cytokines Metabolic disorders Infection Therapy Coincidence

5 SLE: Seizures Seizure or psychosis among 11 primary Dx features Increase mortality (also nephritis & low plts), poor outcome in kids (Andrade et al, 2008; Ward et al, 1995) Seizures 7 40% of pts (~15%), Often symptomatic disease flares; autoantibodies, uremia, hypertension, CNS infection, stroke, at SLE onset, antiphospholipid Abs (Appenzeller et al, Neurology, 2004) Hypertension & posterior reversible encephalopathy syndrome: Altered mental status, headache, visual changes, seizures, posterior leukoencephalopathy Status epilepticus may herald death (West et al, Rheum Dis Clin North Am, 1994)

6 SLE: Antiphospholipid Antibodies Elevated in most studies of seizures/epilepsy Seizures, stroke & HA associated with elevated antiphospholipid Ab (Bertolaccini et al, J Rheum, 2003) Cause vascular disease leading to seizures, also neuropathogenic in vitro (Cimaz et al, Lupus, 2006) Autoantibodies in epilepsy (Ranua et al, Epilepsy Res, 2004) IgG anticardiolipin in 4.5% of ~1000 epilepsy patients but no different than controls, but patients with chronic epilepsy and increased Sz frequency elevated elevated acl? Cause or effect AEDs can induce lupus anticoagulant

7 SLE: Causes of Seizures CSF antineuronal Abs increased in 90% of pts with psychosis, encephalopathy, or seizures v. 11% without CNS disease; 25% of pts with stroke or movement disorder (Bluestein et al, Am J Med, 1981) CSF (not serum) NMDA receptor subunit NR2 Abs correlate with neuropsychiatric Sxs (eg, seizures) (Arinuma et al, Arthritis Rheum, 2008; Kozora et al,j Neurol Sci, 2010) Antiribosomal P protein elevated with CNS disease, including psychosis and seizures (Yoshio et al, J Rheum, 2005) Risk of seizures reduced by anti La Ab and antimalarials (Andrade et al, J Rheum, 2008; Malik et al, Lupus, 2007)

8 SLE: Epilepsy Risk factors for seizure recurrence Overall 12 55% recur Recurrence usually within 1 year of initial Sz Partial seizures >80% recurred Epilepsy in SLE: (Mikdashi et al, Neurology, 2005) higher disease activity at baseline prior neuropsychiatric SLE disease (esp psychosis) anti cardiolipin & anti Smith antibodies Linkage analysis locus on chrom 15 development of seizures in SLE (Bautista, et al, Epilepsia, 2008)

9 SLE: Mitral Valvulitis & Thrombotic Thrombocytopenic Purpura 50 consecutive autopsies (Devinsky et al, Ann Neurol, 1988) No active vasculitis, 2 with evidence of healed vasculitis; dx d in 17 cases (34%) Mitral valvulitis in 23 (46%), 9 with cerebral emboli TTP in 14 (28%) during final terminal illness (2 mos) TTP diagnosis: four of five Microangiopathic hemolytic anemia Thrombocytopenic purpura Renal dysfunction Neurologic disorder Fever

10 Pediatric SLE Seizures reported in 10 40% of cases Neuropsychiatric disorders in 35% (Yu et al, Lupus, 2006) Mortality decreased from 52% ( 85 95) to 28% ( 95 to 05); still the leading cause of death Higher C3/C4 & anticardiolipin Abs Stroke 28% Psychosis 22% Seizures in 85% (Yu et al, 2006) Generalized in 80% Recurred in 63%

11 Sjogren s Syndrome Inflammation & destruction of lacrymal and salivary glands +/ visceral/vasculitic involvement Often associated with other autoimmune disorder (SLE, RA, scleroderma) Neurologic disorders in ~20 25%, PNS = CNS HA, neuropathy & cognitive dysfunction Seizures in 3% of all SS pts), both partial & generalized Often mimic stroke & MS

12 Wegener s Granulomatosis Necrotizing, granulomatous vasculitis of lungs & kidneys Vasculitis affects medium and small arteries Antineutrophil cytoplasmic antibody (ANCA) is often positive in necrotizing vasculitides Neurologic disorders PNS often vasculitis CNS often granulomatous; often from E N T tract & refractory Vasculitis, reversible posterior leukoenceph Seizures can be TC, partial or myoclonic

13 Neurosarcoidosis Sarcoidosis multiorgan noncaseating granulomatous disorder, oligoclonal CD4(+) T cell infiltrates, and immune complexes Neuropath in 10 15%, often asymptomatic Neurologic symptoms ~5% often within 2 years of presentation variable blood and CSF ACE levels 1/50 isolated nervous system disease

14 Neurosarcoidosis DDx MS, ADEM, infection, tumor (eg, lymphoma), vasculitis Neuro Sxs CN palsies 50 80% Parenchymal lesions 50% Enhancing lesions respond to steroids > nonenhancing lesions (Shah et al, Am J Neurorad, 2009) Seizures ~10% in adults, 35% in children (Baumann & Robertson, Pediatrics, 2003) Seizures Often mark severe, relapsing, and progressing disease; can resolve or easily controlled SGTCS and partial seizures If inflammation not controlled, often refractory to AEDs

15 Celiac Disease Neuropathy, ataxia, dementia and seizure disorder all uncommon Malnutrition uncertain;? Vitamin E helps Anti endomysial & antigliadin Abs variable Among 800 CD pts, 21 with seizures (2.6%), 9 with active epilepsy (1.1%) Rarely, CD and refractory epilepsy improve with gluten free diet (Canales et al, Neurologist, 2006)

16 Celiac Disease CD, occipital epilepsy and cerebral calcifications syndrome mostly from Italy, Spain, and Argentina (Gobbi, Brain Dev, 2005) 75 children with Bx proven CD, bilateral T2 WM lesions on MRI in 20% No correlation of MRI with seizures (6 children; febrile 3, single TCS 2; absence 1)(Kieslich et al, Pediatrics, 2001)

17 Crohn s Disease Seizures ~6%(Elshety, South Med J 1997; Hussain & Ahmed, Pak J Neurol Sci, 2006) Mainly TCS, some with SPS and CPS MRI usually normal EEGs normal, or temporal or less often generalized discharges Epilepsy ~4 6% seizures with exacerbation, no longterm AEDs Stroke in ~5 7%, usually unrelated to seizures

18 Behçet s Disease Oral & genital ulcers; skin & eye inflammation Common in Middle East & Asia Epilepsy ~25% of Europeans with neurobehçets (Joseph & Scolding, Eur J Neurol, 2007); stroke in ~5%, usually unrelated to Sz Mainly TCS, some with SPS and CPS EPC may occur MRI usually normal 20 50% of seizures only during exacerbation, no longterm AEDs (Aykutlu et al,epilepsia, 2002)

19 Hashimoto s Encephalopathy Subacute, relapsing remitting course TCS & myoclonus Stroke like episodes Psychiatric disorders, agitation Cognitive decline Autoimmune disorder Steroid responsive Anti thryoid & antineuronal Abs) Perivascular &parenchymal inflammatory infiltrates (Olde et al, J Neurol Sci, 2004; Schiess & Pardo, Ann NY Acad Sci 2004; Mayer & Devinsky, Rev Neurol Dis, 2006)

20 Treatment of Seizures in Systemic Autoimmune Disorders Identify symptomatic causes (eg, metabolic, vascular & infection),? standard AEDs AEDs partial v. generalized epilepsies Immunomodulatory therapies challenging balance Steroids anti inflammatory, immunosuppressive Cytostatics Alkylating (eg, cyclophosphamide) Antimetabolics (eg, methotrexate, azothiaprine) IVIG & Plasmapheresis Antibodies mono & polyclonal Immunophilins cyclosporine, tacrolimus Interferons TNF alpha

21 Conclusions Seizures often complication systemic autoimmune disorders (SAD) Infrequently presenting feature of SAD Examine for skin lesions, oral ulcers, iritis, pulmonary, renal symptoms, etc Consider ESR, CRP, ANA, ACE, ACNA In sick SLE patient, look at the blood smear Repeat initial exam and imaging Enormous opportunity to uncover mechanisms and therapies