|Year : 2020 | Volume
| Issue : 1 | Page : 54-57
Multimodality imaging of anti-contactin-associated protein-like 2 antibody-induced nonparaneoplastic limbic encephalitis: Complementary role of fluorine-18 fluorodeoxyglucose positron emission tomography and magnetic resonance imaging
Kasturi Rangan1, Manish Ora1, Neeraj Jain2, Amrin Israrahmed2, Sanjay Gambhir1
1 Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
2 Department of Radiodiagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
|Date of Submission||26-Sep-2019|
|Date of Acceptance||09-Oct-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Manish Ora
F Block, Department of Nuclear Medicine, SGPGIMS, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Autoimmune limbic encephalitis (AE) is an autoimmune-mediated inflammation typically affecting the medial temporal lobes and other limbic structures (cingulate gyrus, orbital cortex, and hypothalamus). It can be associated with underlying malignancy as a paraneoplastic syndrome. Nonparaneoplastic AE is a difficult disease to diagnose and often requires the collaboration of multiple modalities for effective diagnosis and treatment. We describe an interesting case of contactin-associated protein-like 2 antibody-associated nonparaneoplastic limbic encephalitis on fluorine-18 fluorodeoxyglucose positron emission tomography and magnetic resonance imaging.
Keywords: Autoimmune encephalitis, flurodeoxyglucose positron emission tomography, magnetic resonance imaging
|How to cite this article:|
Rangan K, Ora M, Jain N, Israrahmed A, Gambhir S. Multimodality imaging of anti-contactin-associated protein-like 2 antibody-induced nonparaneoplastic limbic encephalitis: Complementary role of fluorine-18 fluorodeoxyglucose positron emission tomography and magnetic resonance imaging. Indian J Nucl Med 2020;35:54-7
|How to cite this URL:|
Rangan K, Ora M, Jain N, Israrahmed A, Gambhir S. Multimodality imaging of anti-contactin-associated protein-like 2 antibody-induced nonparaneoplastic limbic encephalitis: Complementary role of fluorine-18 fluorodeoxyglucose positron emission tomography and magnetic resonance imaging. Indian J Nucl Med [serial online] 2020 [cited 2020 Feb 25];35:54-7. Available from: http://www.ijnm.in/text.asp?2020/35/1/54/274372
| Introduction|| |
Autoimmune limbic encephalitis (AE) is an autoimmune-mediated inflammation typically affecting the medial temporal lobes and other limbic structures (cingulate gyrus, orbital cortex, and hypothalamus). Patients show rapidly progressive short-term memory deficits, psychiatric symptoms, and seizures. In patients whose presentation is consistent with that of AE, testing typically used to aid in the diagnosis of AE includes magnetic resonance imaging (MRI) of the brain with contrast, electroencephalogram (EEG), and blood and cerebrospinal fluid analysis for the markers of inflammation. However, negative test results for autoimmune antibodies does not rule out AE. A significant percentage of AE cases may be caused by other, still unknown antibodies, or by known antibodies for which a diagnostic test is not yet available. We present a rare clinical case of anti-contactin-associated protein-like 2 (anti-CASPR2) antibody limbic encephalitis and discuss various findings on fluorine-18 fluorodeoxyglucose positron emission tomography computed tomography (F-18 FDG PET/CT) and MRI.
| Case Report|| |
A 62-year-old male has been reported with complaints of behavioral changes in the form of irritability, anger, delusions, and poor attention. He also had multiple episodes of generalized tonic–clonic seizures, giddiness on standing, urinary incontinence, constipation, and insomnia for 4 months.
On examination, he was conscious but disoriented with poor attention span. He also had asterixis, myoclonic jerk, dysarthria, brisk deep-tendon reflexes, and postural hypotension (supine blood pressure 160/100 mmHg-standing blood pressure 80/60 mmHg). Cranial nerve examination, sensory system, and cerebellar signs were normal.
Routine blood investigations, including hemogram, serum electrolytes, biochemistry, viral markers, thyroid profile, and complete cerebrospinal fluid analysis, were normal. EEG showed diffuse delta waves slowing with no triphasic waves. His serum thyroid-stimulating hormone and Vitamins B12 level were normal. Clinical suspicion of neurodegenerative disorder, paraneoplastic encephalitis, or Creutzfeldt–Jakob disease was considered differentials.
MRI imaging of the brain was performed, as described below. F-18 FDG PET/CT was performed 2 days after MRI brain.
Magnetic resonance imaging
MRI revealed hyperintense signal in bilateral medial temporal lobes on T2 and fluid-attenuated inversion recovery (FLAIR) sequences with more pronounced involvement on the right side. T1 images show subtle hypointense signal; however, no enhancement or diffusion restriction was noted. Some nonspecific foci with FLAIR hyperintense signals were seen in the right frontal lobe. No significant changes were seen in both the basal ganglia. On the basis of MRI findings, the possibility of limbic encephalitis was suggested [Figure 1].
|Figure 1:T2 Weighted (a) Axial image shows hyperintense signal in the right medial temporal lobe(green arrow). On fluid-attenuated inversion recovery (b) Image hyperintense signal in the right medial temporal lobe is more noticeable and in addition, the left medial temporal lobe also shows subtle hyperintense signal(white arrow). T1 precontrast axial image(c) shows hypointense signal in the right medial temporal lobe, while postcontrast axial image (d) shows no abnormal enhancement|
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Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography
The patient was referred for F18-FDG PET/CT imaging for further evaluation and to rule out the possibility of the paraneoplastic etiology. PET/CT imaging was performed by an integrated scanner (Biograph™ scanners, PET/CT scanner, Siemens Healthineers, SSP map generation by syngo. MI Neuro software Software-Syno.via MI Neuro Machine-True Point PET-CT System, Biograph 64, Siemens, Germany). Apart from standard PET/CT acquisition, a separate dedicated PET/CT brain images were taken for 5 min in three-dimensional acquisition mode. F-18 FDG-PET showed hypermetabolism in bilateral medial temporal lobes and small patchy areas in the right anterior frontal lobe and left parietal lobe region. symmetrically preserved metabolism was noted in both the basal ganglia [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. Moderate hypometabolism was noted in the rest of the brain parenchyma. Stereotactic surface projection images revealed the same findings [Figure 2]g, [Figure 2]h, [Figure 2]i. The rest of the body did not show any abnormal FDG uptake.
|Figure 2: Fluorodeoxyglucose positron emission tomography–computed tomography. Upper row (a-c) shows computed tomography scan, which is unremarkable Middle row (fused positron emission tomography–computed tomography) shows global hypometabolism (d, yellow arrow), hypermetabolism in bilateral medial temporal lobes (e, white arrow, right > left), and small area of preserved metabolism in the right anterior frontal lobe (star) and left parietal lobe region (white dot). Symmetrical uptake was noted in the caudate and putamen (f red arrow). The lower row (g-i) shows stereotactic surface projection images that revealed the same findings as on fused positron emission tomography–computed tomography images (blue color represents the reduced uptake and the red color revealing the increased uptake of fluorodeoxyglucose). Red color is more pronounced in the medial temporal lobes, right anterior frontal and left partial lobe|
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In view of clinical appearance, MRI and PET/CT findings, a probable diagnosis of nonparaneoplastic limbic encephaliti (NPLE) was made, and antibody panel was ordered. It was positive for antibodies against anti-CASPR2. The patient was started on IV methylprednisolone 500 mg IV/day for 10 days. In view of no response to the steroid, IV immunoglobulin was started. The patient symptomatically improved over next 1 week, he became interactive and oriented, but autonomic dysfunction persisted. The patient was discharged and advised to follow-up.
| Discussion|| |
LIMBIC encephalitis presents with varied symptoms, signs, and nonspecific findings on MRI. The high level of suspicious is required for the diagnosis. Paraneoplastic autoimmune limbic encephalitis develops in the presence of an underlying malignancy such as carcinoma lung, thymic, breast, renal, colonic, and ovarian carcinomas. Diagnosis of AE is based on clinical clues in the recognition of particular types AE, exclusion of other autoimmune disorders, infectious and medical causes, antibody testing, and imaging. Patients present with various overlapping symptoms such as psychosis, dystonia, hyperekplexia, seizures, dystonia, and spasm. Various antibodies against intracellular and cell surface antigens have been described. NPLE has no underlying malignancy and responds favorably to immunotherapy. Various kinds of antibodies have been linked with AE. One of the rare kinds of antibody is directed against CASPR2. It has been described in the sera of patients with peripheral and central neurological syndromes, including neuromyotonia, Morvan syndrome, and autoimmune limbic encephalitis. Patient with anti-CASPR2 antibodies AE presents with limbic symptoms, including temporal lobe seizures, memory disorders, and cerebellar ataxia.
Imaging findings on the MRI are nonspecific. It presents as T2 hyperintensity in the FLAIR sequence. Diffusion-weighted imaging positivity and/or enhancement are rarely seen in AE. MRI rules out other pathologies of the brain. Patients can also have normal MRI imaging of the brain, especially in those patients with cell surface-targeted autoantibodies. In a large series of patients with NMDARE, only about one-third of the patients demonstrated any abnormality on brain MRI.
Being a metabolic whole-body imaging, F-18 FDG-PET/CT solves two purposes. It not only rules out paraneoplastic etiology and is more commonly abnormal in AE in comparison to MRI. Abnormalities may be detected on the PET/CT with a normal MRI scan. The frequency of metabolic abnormalities is much greater than that of diagnostic studies currently included in consensus criteria for the diagnosis of AE. F-18 FDG PET/CT in AE usually shows hypermetabolism in the mesial temporal and orbitofrontal cortex, occipital hypometabolism, and symmetrical hypermetabolism in the corpus striatum and amygdala.
| Conclusion|| |
AE is a difficult clinical diagnosis; it is a diagnosis by exclusion. MRI may show abnormality only in one-third of the patients. Symptoms are usually out of the proportion of MRI finding, and normal MRI does not exclude AE. Whole-body FDG PET/CT has high probability in identifying AE, and it can rule out paraneoplastic limbic encephalitis with good accuracy. FDG PET/CT may represent a sensitive and early biomarker for AE, and it has potential to become an important tool in the diagnosis and understanding pathophysiology of AE.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gultekin SH, Rosenfeld MR, Voltz R, Eichen J, Posner JB, Dalmau J, et al.
Paraneoplastic limbic encephalitis: Neurological symptoms, immunological findings and tumour association in 50 patients. Brain 2000;123 (Pt 7):1481-94.
Lancaster E. The diagnosis and treatment of autoimmune encephalitis. J Clin Neurol 2016;12:1-3.
Ances BM, Vitaliani R, Taylor RA, Liebeskind DS, Voloschin A, Houghton DJ, et al.
Treatment-responsive limbic encephalitis identified by neuropil antibodies: MRI and PET correlates. Brain 2005;128:1764-77.
Irani SR, Alexander S, Waters P, Kleopa KA, Pettingill P, Zuliani L, et al.
Antibodies to kv1 potassium channel-complex proteins leucine-rich, glioma inactivated 1 protein and contactin-associated protein-2 in limbic encephalitis, Morvan's syndrome and acquired neuromyotonia. Brain 2010;133:2734-48.
Joubert B, Saint-Martin M, Noraz N, Picard G, Rogemond V, Ducray F, et al.
Characterization of a subtype of autoimmune encephalitis with anti-contactin-associated protein-like 2 antibodies in the cerebrospinal fluid, prominent limbic symptoms, and seizures. JAMA Neurol 2016;73:1115-24.
Armangue T, Moris G, Cantarín-Extremera V, Conde CE, Rostasy K, Erro ME, et al.
Autoimmune post-herpes simplex encephalitis of adults and teenagers. Neurology 2015;85:1736-43.
Titulaer MJ, McCracken L, Gabilondo I, Armangué T, Glaser C, Iizuka T, et al.
Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: An observational cohort study. Lancet Neurol 2013;12:157-65.
Probasco JC, Solnes L, Nalluri A, Cohen J, Jones KM, Zan E, et al.
Abnormal brain metabolism on FDG-PET/CT is a common early finding in autoimmune encephalitis. Neurol Neuroimmunol Neuroinflamm 2017;4:e352.
Fisher RE, Patel NR, Lai EC, Schulz PE. Two different 18F-FDG brain PET metabolic patterns in autoimmune limbic encephalitis. Clin Nucl Med 2012;37:e213-8.
[Figure 1], [Figure 2]