A review of laboratory tests. in autoimmune disorders and other neuroinflammatory conditions

Transcription

1 A review of laboratory tests in autoimmune disorders and other neuroinflammatory conditions

2 Wieslab is Scandinavia s largest private specialized laboratory for diagnosis of autoimmune diseases. Wieslab was founded in 1991 and has been part of Euro Diagnostica since Wieslab was one of the first private laboratories accredited by SWEDAC and currently works in ISO / IEC 17025: 2005 and thereby meets the high standards for laboratories within the EU. Early and reliable diagnosis is crucial to provide adequate treatment before permanent tissue damage with consequent impairment have arisen. More and more diagnostic markers are being identified and Wieslab actively strives to be at the forefront of this development. This is to be able to offer an adequate range of diagnostic analysis for both rare and better-known diseases. To achieve this we have several national and international partners. The goal for Wieslab is to offer cost-effective laboratory tests of good quality and also assist with expertise and counselling. Wieslab wants to give customers an optimal basis for diagnosis, monitoring and treatment of autoimmune diseases. Since May 2015, Wieslab has been part of SWEDAC programs for Good Laboratory Practice (GLP) according to STAFS 2008:4. Wieslab is GLP-approved to perform bioanalytical testing in non-clinical safety studies of drugs (Analytical and Clinical Chemistry Testing). Wieslab also performs bioanalytical testing for clinical trials according to EU directives 2001/20 / EC, FDA Title 21 part 58 (21CFR58), and EMA / INS / GCP / /2010. With an accredited laboratory in Malmö, Sweden, Wieslab is ideally located to ensure fast, full-service testing in autoimmunity within the Nordic countries, but also welcomes samples from all around the world. 2 I A REVIEW OF LABORATORY TESTS

3 Dear Reader, Autoimmune diseases include a wide variety of medical conditions and can affect most organs of the body. Depending onwhich organ is affected, the clinical course and the disease severity are very variable. In recent years, several autoimmune and paraneoplastic syndromes that affect the nervous system have been identified. They represent a broad spectrum, from more better-known and common diagnoses to less-known and rare conditions. The development of knowledge concerning both pathogenesis, diagnostics and treatment in this area is growing rapidly and many of these conditions can today be successfully treated. In this booklet, we have made a compilation of relevant markers that can be analyzed on suspicion and monitoring of various neuro inflammatory conditions. This document has been prepared to support you in your everyday clinical practice and answer common questions regarding sampling, but it is also intended to provide guidance on the appropriate analysis to order. In the center pages, please find, an overview of markers and their link to different symptoms/diagnoses. We hope that you will benefit from this compilation. If you have questions or comments - please contact us via info@wieslab.com. Malmö, June 2016 Michael Akoh Vice President mia@wieslab.com Monica Blixt Sr Key Account Manager mob@wieslab.com Rita Martins Olofsson Laboratory Manager rmo@wieslab.com I 3

4 Sampling Instructions (Please see a request form for further information) Autoantibody assays - Serum All samples for autoantibody assays should be taken in plain tubes without coagulents or other additives. The serum sample must be kept in the fridge waiting for transport, and can sent at room temperature by regular mail. 3 ml of serum (7 ml of whole blood) is enough for about 15 analyses. Autoantibody assays - CSF For cerebrospinal fluid - use standard polypropylene tubes. Samples do not need to be frozen, but kept in the fridge pending transport and can be sent at room temperature by regular mail. 3 ml CSF is enough for about 10 analyses. Analysis of biomarkers in cerebrospinal fluid Parenchymal injury markers: CSF distributed in cryogenic vials made of polypropylene, which should be frozen within 24 hours from collection and shipped with dry ice in a Styrofoam box. Alzheimer markers (Tau, Phospho-tau, Beta-amyloid) 3 tubes x 0.5 ml cerebrospinal fluid. Parenchymal injury markers (Neurofilament light protein (NFL), Glial fibrillry acidic protein (GFAp), Tau) 3 tubes x 0.5 ml cerebrospinal fluid. Neuromyelitis Optica Spectrum Disease (NMOSD) (NFL, GFAp) 2 tubes x 0.5 ml cerebrospinal fluid. The sampling and testing for: Narcolepsy (orexin/hypocretin, HLA-DQB1 * 06: 02, and anti-trib2) 1 tube, 3 ml serum 1 tube, 2.5 ml plasma (EDTA tube) 1 tube, 0.5 ml cerebrospinal fluid (see instructions for biomarkers in cerebrospinal fluid - above.) The client is responsible for the transportation of samples to Wieslab 4 I A REVIEW OF LABORATORY TESTS

5 Analytical methods for the detection of antibodies used at Wieslab AB; ELISA (enzyme-linked immunosorbent assay) The antigen is attached to a plastic surface. The patient sample is added and if it contains specific antibodies they will bind to the antigen. Next - enzyme labeled antibodies to human IgG is added. Finally - a substance that changes color on contact with the enzyme is added. The color intensity is quantified in a spectrophotometer. The amount mirrors the amount of antibodies that have bound to the antigen. RIA (Radioimmunoassay) Works in very much the same way as an ELISA but here the antigen is labeled with a radioactive isotope. The reading is done using a gamma counter and the degree of radioactivity reflects the amount of antibodies that have bound to the antigen. Immunoblot Consists of similar steps as an ELISA and RIA but the antigen is attached in the form of tape on a membrane. Detection antibodies labeled with an enzyme and a substance which gives a dark color on contact with the enzyme are added. The color intensity of the antigen band reflects the amount of antibodies that have bound to the antigen. Indirect immunofluorescence Upon examination by indirect immunofluorescence investigation tissue sections (usually rat or monkey) or cultured cells are used as the antigen source for detection of autoantibodies. Fluorochrome-stained antibodies directed to human IgG is added. Various antigens are differently distributed in the cells/tissue and depending on the means of antigens autoantibodies bound to arise different fluorescent lighting pattern at the fluorescence microscope. The fluorescence pattern can be read and used to identify the auto antibodies specificity. For more information about the different methods of analysis and specific information of the various tests for antigens, please visit our website: I 5

6 Antigen / Neuronal antibodies - an Overview Diagnosis/ Medical condition Antibodies towards Typical symtoms Diagnosis Sample Method Extracellular (EC)/ Intracellular (IC) antigen Publications Association to cancer diagnosis Most common cancerdiagnosis associated to the antibodies 1-4 Reference Order number on Wieslab Request Form (Package analysis) Order number on Wieslab Request Form (individual analysis) AMPAR 1 & 2 (glutamatreceptor 1 and 2) Psychiatric, cognitive symtoms Serum (CSF) IIF EC % Thymoma, bronchial cancer, breast cancer, SCLC NMDA receptor (N-metyl-D-aspartat) Psychiatric symptoms, convulsions, dyskinesia, dystonia, autonom instability Serum (CSF) IIF EC > % Teratoma (ovarian, testis) 553, 556, , 556, , 6 1-3, 5 GABA B R (gamma-aminobutyric acid-b receptor) LGI-1 (VGKC) (leucine rich glioma-inactivated protein 1) Convulsions Serum (CSF) IIF EC 25 47% Amnesia, convulsions, psychiatric change, dystonia Serum (CSF) IIF EC > % SCLC (70%), neuroendocrine tumour SCLC, thymoma, adenocarcinoma (kidney, thyroid, breast), prostate cancer, ovarian teratoma 553, 556, , 556, , , 7-8 CASPR-2 (VGKC) (contactin associated protein 2) DPPX (dipeptidyl-peptidase-like protein-6) Morvans syndrome with confusion, amnesia, insomnia, autonom dysfunction, neuromyotonia, pain Cognitive symptoms, restlessness, hallucinations, muscle spasm, tremor. Pleocytosis in CSF. Weightloss and Diarrhea as prodromal symptoms Serum (CSF) IIF EC 40 <40% Tymom, SCLC Serum (CSF) IIF EC N.A. N.A. N.A. 553, 556, , 556, 851 8, , VGKC (voltage gated potassium channel complex) Autoimmune encefalitis Serum RIA EC Hu (Anna-1) (anti-neuronal nuclear antibody 1) Encephalomyelitis, autoimmune encefalitis, Brainstemencefalitis, sensory and autonomic neuropathy Serum (CSF) Blot/IIF IC >600 98% 80% SCLC 553, ,3, ,3,10-11 Yo (PCA-1) (Purkinje cell cytoplasmic antibody type 1) Subacute cerebellar ataxia, sensory and motor neuropathy Serum (CSF) Blot/IIF IC >200 98% Ovarian carcinoma, breast cancer Ri (Anna-2, Nova 1) (anti-neuronal nuclear antibody 2) Paraneoplastic opsoclonus - myoclonus, Brainstemencefalitis Serum (CSF) Blot/IIF IC 61 97% Breast cancer, gynecological cancer, SCLC ,3, ,3,10-11 CV2/CRMP5 (collapsing response mediator protein 5) Amphiphysin Motor and sensory neuropathy, chorea, autoimmune encefalitis, optic neuritis, myelitis Stiff person syndrome, encefalomyelitis, sensory and motor neuropathy Serum (CSF) Blot/IIF IC >100 96% SCLC, thymoma, carcinoma (thyroid, kidney) Serum (CSF) Blot/IIF IC 20 95% SCLC, breast cancer 870, 563, syndrome Autoimmune encefalitis 1,3, VGKC channel is a complex of several proteins, amongst others LGI1 and CASPR2. The analysis of anti-vgkc antibodies can thus give positive results even if the individual LGI1 / CASPR2 analyzes are negative.

7 1,3, Ma2/Ta (anti-paraneoplastic Ma2, PNMA2) Autoimmun encefalitis, Brainstemencefalitis, hypotalamusencefalitis Serum (CSF) Blot/IIF IC 55 96% Breast cancer, testicular cancer, SCLC , 43 Tr (Trotter - purkinjecell) Encefalomyelitis, cerebellar degeneration Serum (CSF) IIF IC 28 89% Hodgkins lymphoma, breast cancer, ovarian cancer, SCLC, thymoma 554, SOX 1 (AGNA anti-glial-nuclear antibody) Paraneoplastic neuropati, LEMS, ataxia, neuropathy Serum Blot IC N.A N.A SCLC 554, 737 1,3, ZIC 4 (Zinc finger of the cerebellum 4) Paraneoplastic cerebellar degeneration Serum (CSF) Blot IC N.A N.A SCLC 554, 742 Recoverin 39 CAR (cancer associerad retinopati) Serum (CSF) Blot N.A N.A Malignant melanoma, SCLC 554,, Titin 40,41 Myastenia Gravis Serum (CSF) Blot N.A N.A Thymoma 554,, GAD (Glutamic Acid Decarboxylase 65 & 67, (Pankreas 65 & Brain 65 & 67) Stiff person syndrome (60%), cerebellar degeneration, autoimmune encefalitis, epilepsy, Diabetes Mellitus Typ 1 Serum ELISA/ IIF IC N.A 8% Thymoma, cancer (kidney, breast, colon) 563, Less frequent antibody specificities 39 Anna-3 (purkinjecell) Sensory and motor neuropathy with or without Ataxia Serum (CSF) IIF IC N.A Has been described SCLC, carcinoma (breast, lung, esophagus) CARP VIII (purkinjecellprotein) Cerebellar degeneration Serum (CSF) IIF IC N.A Has been described SCLC, breast cancer, malignant melanoma , Glycine receptor Stiff person syndrome, progressive encefalomyelitis with rigidity and myoclonus (PERM) Serum (CSF) IIF EC N.A 10% N.A 562, HOMER 3 (homer scaffolding protein 3) Subacute cerebellar ataxi Serum (CSF) IIF N.A N.A N.A IgLON 5 (IgLON family member 5) 24,26 Encefalitis and neurodegeneration abnormal sleeping pattern (parasomnia), obstructive sleep apnea, abnormal walking pattern, dysarthria, dysphagia, ataxia, chorea Serum (CSF) IIF EC Few cases reported N.A N.A ITPR 1 (Inositol 1,4,5-Trisphosphate Receptor, Type 1) Subakut cerebellar ataxia Serum (CSF) IIF IC N.A N.A N.A PCA-2 (Purkinje cell cytoplasmic antibody type 2) Encefalomyelitis, cerebellar degeneration Serum (CSF) IIF IC N.A Has been described Breast cancer, ovarian cancer, SCLC ,3, VGCC (voltage gated calcium channel complex) Neuropathy, LEMS, cerebellar dysfunction Serum (CSF) RIA N.A 50-60% SCLC (50-60%), Lymphoma 562, N.A - Data not available CSF - Cerebrospinal fluid RIA - Radioimmunoassay IIF - Immunoflourescens (transfected cells) Blot - Western immunoblot ELISA - Enzyme-linked immunosorbent assay EC - Plasma membrane antigen-antibodies IC - Neuronal & Cytoplasmic antibodies SCLC - Small cell lungcarcinoma LEMS - Lambert-Eaton myasthenic syndrom PERM - Progressive encephalomyelitis with rigidity and myoclonus Paraneoplastisc

8 Assays for the detection of autoantibodies: Autoimmune encephalitis and paraneoplastic syndromes can be ordered acute, meaning they are analysed the next working day after the samples arrival at the laboratory. If the sample arrives before am on a weekday the assay will be performed on the same day. This applies packages 556 and 557. In addition to the acute tests the following packages can be ordered: Package 553 Package 554 Package Package 562 Autoimmune encephalitis (follow-up of acute package 557) Paraneoplastic syndromes, cerebellar degeneration, cerebellar ataxia (follow-up of acute package 556) Autoimmune encephalitis, paraneoplastic syndromes, cerebellar degeneration, and cerebellar ataxia Extended analysis of anti-neuronal antibodies Response time for these tests is estimated at one working week. A detailed description of these tests can be found on pages 5 and 6 of this booklet. In order to facilitate decisions on the autoantibodies that are appropriate to test with various suspected symptoms, Wieslab has made it possible to choose test packages for the suspected disease on the front page of the request forms. Test packages recommended according to disease suspicion: Lambert Eaton myasthenic syndrome (LEMS) (Package No. 563) Antibodies against voltage gated calcium channels (VGCC), acetylcholine receptor (anti-achr), GAD, Hu, Ri, SOX1. Myasthenia Gravis (Package No. 543) Antibodies against striated muscle and acetylcholine receptor (Anti-AChR). Upon positive response to anti-achr supplemented with anti-titin (Screening) and in negative results for anti-achr completed with anti-musk. Narcolepsy (Package No. 558) Orexin / hypocretin, HLA-DQB1 * 0602 tissue and Trib2 antibodies. 8 I A REVIEW OF LABORATORY TESTS

9 Neuromyelitis Optica Spectrum Disease (NMOSD) (Package No. 565) Antibodies against Aquaporin 4 and myelin oligodendrocyte glycoprotein (MOG) Supplementary analysis of biomarkers in suspected NMOSD (Package No. 559) Neurofilament light protein (NFL), Glial fibrillary acidic protein (GFAP) Neuropathy unclear / Guillain-Barre (Package No. 534) Antibodies against gangliosides (IgG and IgM), GM1, GM2, G01a, G01b, GQ1b MAG (IgG) and IgM sulphatide PANDAS / PANS - pediatric autoimmune neuropsychiatric syndrome (Package No. 564) Antibodies against Dopamine receptor (D1 and D2) lyso GM1, beta-tubulin and CaM kinase II activation Paraneoplastic retinopathy (MAR CAR) (Package No. 569) Antibodies to Alpha-Enolase and Recoverin Polymyositis / Dermatomyositis and other autoimmune myositis (Package No. 551) Antibodies against EJ, HMGCR, Mi-2, PL-7, PL-12, PM / Scl, SRP and ANA and ENA screen. Advanced analysis for autoimmune myositis and scleroderma overlap syndrome (Package No. 552) Antibodies against OJ, KS, KU, Trytophanyl trna Synthatase, RNA polymerase I, II, III Stiff Person Syndrome / PERM (Package No. 568) Antibodies against amphiphysin, GAD and glycine receptor Neuro-inflammatory conditions follow-up of biomarkers may be useful: Alzheimer s disease (Package No. 567) Tau, phospho-tau, beta amyloid CNS Parenchymal injury markers (Package No. 566) Neurofilament light protein (NFL): axonal injury, Glial fibrillary acidic protein (GFAp): astrocyte injury, Tau: neurodegeneration I 9

10 Reference list Ref. no Antigen Pub Med Id no 1 AMPAR 1 & 2, SOX 1, NMDA, GABA Br, LGI-1, CASPR 2, DPPX, Hu, Yo, Ri, Amphiphysin, CV2/CRMP5, Ma2/Ta, Glycine receptor, VGCC, ZIC4 Lancaster et al. Encephalitis and antibodies to synaptic and neuronal cell surface proteins. Neurology Jul 12;77(2): AMPAR 1 & 2, NMDA, GABA Br, LGI-1, CASPR2 Titulaera et al. Screening for tumours in paraneoplastic syndromes: report of an EFNS Task Force. European Journal of Neurology. Epublished Eur J Neurol January; 18(1): AMPAR 1 & 2, SOX 1, NMDA, GABA Br, LGI-1, CASPR-2, Glycine receptor, Hu, Yo, Ri, Amphiphysin, CV2/CRMP5, Ma2/Ta, Glycine receptor, VGCC, ZIC4 Zuliani et al. Central nervous system neuronal surface antibody associated syndromes: review and guidelines for recognition. J Neurol Neurosurg Psychiatry 2012;83: AMPAR 1 & 2 Lai, et al. AMPA receptor antibodies in limbic encephalitis alter synaptic receptor location. Ann Neurol 2009;65: NMDA 6 GABA Br 7 LGI-1 8 LGI-1, CASPR-2, VGKC Dalmau et al. Paraneoplastic anti- N-metyl-D-aspartat receptor encephalitis associated with ovarian teratoma. Ann Neurol 2007;61: Lancaster, et al. Antibodies to the GABA(B) receptor in limbic encephalitis with seizures: case series and characterisation of the antigen. Lancet Neurol 2010;9: Lai, et al. Investigation of LGI1 as the antigen in limbic encephalitis previously attributed to potassium channels: a case series. Lancet Neurol 2010;9: Irani SR, et al. Antibodies to Kv1 potassium channelcomplex proteins leucine-rich, glioma inactivated 1 protein and contactin-associated protein-2 in limbic encephalitis, Morvan s syndrome and acquired neuromyotonia. Brain 2010;133: CASPR-2 Lancaster E et al. Investigations of caspr2, an autoantigen of encephalitis and neuromyotonia. Ann Neurol 2011;69: GAD Hu, Yo, Ri, Amphiphysin, CV2/CRMP5, Ma2/Ta, Glycine receptor, VGCC, ZIC4 Hu, Yo, Ri, Amphiphysin, CV2/CRMP5, Ma2/Ta, Glycine receptor, VGCC, ZIC4 Roberts WK1, Darnell RB. Neuroimmunology of the paraneoplastic neurological degenerations. Curr Opin Immunol Oct;16(5): Graus F et al. Recommended diagnostic criteria for paraneoplastic neurological syndromes. J Neurol Neurosurg Psychiatry Aug;75(8): Saiz et al. Spectrum of neurological syndromes associated with glutamic acid decarboxylase antibodies: diagnostic clues for this association. Brain Oct;131(Pt 10): GAD Vincent. Stiff, twitchy or wobbly are GAD antibodies pathogenic? Brain (10): VGKC 15 VGKC Hart et al. (1997). Autoantibodies detected to expressed K+ channels are implicated in Neuromyotonia. Ann Neurol 41: Vincent A. et al. (2004). Potassium channel antibody-associated encephalopathy: a potentially immunotherapy-responsive form of limbic encephalitis. Brain 127: VGKC Tan K. et al. Clinical spectrum of voltage-gated potassium channel autoimmunity. Neurology 70: VGKC Harrower T. et al. (2006). A case of voltage-gated potassium channel antibody-related limbic encephalitis. Nature 2:6: VGKC 19 CARP VIII 20 CARP VIII Olberg H. et. al. Neurological manifestations related to level of voltage-gated potassium channel antibodies. J Neurol Neurosurg Psychiatry Aug;84(8): Bataller L, et.al., Carbonic anhydrase-related protein VIII: autoantigen in paraneoplastic cerebellar degeneration, Ann Neurol Oct;56(4): Höftberger R, et.al., Carbonic anhydrase-related protein VIII antibodies and paraneoplastic cerebellar degeneration, Neuropathol Appl Neurobiol Aug;40(5):

11 21 DPPX Boronat A, et al. Encephalitis and antibodies to dipeptidyl-peptidase-like protein-6, a subunit of Kv4.2 potassium channels. Ann Neurol 73 (2013) DPPX, IgLON5 Frank Leypoldt, et.al. Autoimmune encephalopathies Ann. N.Y. Acad. Sci. (2014) HOMER 3 Höftberger R et.al. Patient with homer-3 antibodies and cerebellitis, JAMA Neurol Apr;70(4): IgLON5 Sabater L et. al. A novel non-rapid-eye movement and rapid-eye-movement parasomnia with sleep breathing disorder associated with antibodies to IgLON5: a case series, characterisation of the antigen, and post-mortem study. Lancet Neurol Jun;13(6): ITPR1 Sven Jarius, et.al., Antibodies to the inositol 1,4,5-trisphosphate receptor type 1 (ITPR1) in cerebellar ataxia, Journal of Neuroinflammation, 2014, 11: SOX1 Stich et al. Acta Neurol Scand. 2012;125(5): SOX1 Tschernatsch et al. Autoimmun Rev Jun;8(7): Achr -ganglionära 29 Achr -ganglionära 30 Aquaporin 4 31 Aquaporin 4 Vernino S, et al. Autoantibodies to ganglionic acetylcholine receptors in autoimmune autonomic neuropathies. N Engl J Med Sep 21;343(12): Koike H, et al. The spectrum of immune-mediated autonomic neuropathies: insights from the clinicopathological features. J Neurol Neurosurg Psychiatry Jan;84(1): Ruiz-Gaviria R, et al. Specificity and sensitivity of aquaporin 4 antibody detection tests in patients with neuromyelitis optica: A meta-analysis. Mult Scler Relat Disord Jul;4(4): doi: /j.msard Epub 2015 Jun 17. Zekeridou A, Lennon VA. Aquaporin-4 autoimmunity. Neurol Neuroimmunol Neuroinflamm May 21;2(4):e110. doi: /NXI ecollection Aquaporin 4 Melamed E et al. Update on biomarkers in neuromyelitis optica. Neurol Neuroimmunol Neuroinflamm Jul 23;2(4):e Aquaporin 4 34 Aquaproin 4, MOG 35 MOG 36 MOG 37 ANNA-3 38 PCA-2 Yin J, et al. Clinical manifestations of neuromyelitis optica in male and female patients. Neurol Res Jul 27: Y Höftberger R, et al. Antibodies to MOG and AQP4 in adults with neuromyelitis optica and suspected limited forms of the disease. Mult Scler Jun;21(7): doi: / Epub 2014 Oct 24. Tanaka M, Tanaka K. Anti-MOG antibodies in adult patients with demyelinating disorders of the central nervous system. J Neuroimmunol May 15;270(1-2):98-9. Epub 2014 Mar 11. Pröbstel AK, et al. Anti-MOG antibodies are present in a subgroup of patients with a neuromyelitis optica phenotype. J Neuroinflammation Mar 8;12:46. doi: /s Chan KH et al. ANNA-3 anti-neuronal nuclear antibody: marker of lung cancer-related autoimmunity. Ann Neurol Sep;50(3): Vernino S, Lennon VA. New Purkinje cell antibody (PCA-2): marker of lung cancer-related neurological autoimmunity. Ann Neurol Mar;47(3): Recoverin Braithwaite T. et al. Autoimmune retinopati. Ophthalmologica. 2012;228(3): Titin Romi et al. Complement activation by titin and ryanodine receptor autoantibodies in myasthenia gravis. Arch Neurol Nov;57(11): Titin Romi et al. Muscle autoantibodies in subgroups of myasthenia gravis patients. J Neurol May;247(5): Tr (trotter) Bernal F. et al. Anti-Tr antibodies as markers of paraneoplastic cerebellar degeneration and Hodgkin s disease. Neurology 2003;60: Tr (trotter) Briani C. et al. Spectrum of paraneoplastic disease associated with lymphoma. Neurology 2011;76:

12 Wieslab AB Doc No: W-023-GB00, June 2016 Mail address: P.O. Box SE Malmö Sweden Visiting address: Lundavägen 151 Malmö Sweden T F E W info@wieslab.com