MDS2 - Overview: Movement Disorder, Autoimmune/Paraneoplastic Evaluation, Serum (2023)

If the immunofluorescence assay (IFA) patterns suggest amphiphysin antibody, then amphiphysin immunoblot (IB) and amphiphysin titer will be performed at an additional charge.

If the IFA pattern suggests antiglial nuclear antibody-1 (AGNA)-1, then AGNA-1 IB and AGNA-1 titer will be performed at an additional charge.

If the IFA pattern suggests antineuronal nuclear antibody type 1 (ANNA-1), then ANNA-1 IB, ANNA-1 titer, and ANNA-2 IB will be performed at an additional charge.

If the IFA pattern suggests ANNA-2 antibody, then ANNA-2 IB, ANNA-2 titer, and ANNA-1 IB will be performed at an additional charge.

If client requests or the IFA pattern suggests ANNA-3 antibodies, then ANNA-3 titer will be performed at an additional charge.

If the IFA pattern suggests adaptor protein 3 beta 2 (AP3B2) antibodies, then AP3B2 cell-binding assay (CBA) and AP3B2 titer will be performed at an additional charge.

If collapsin response-mediator protein-5 (CRMP-5)-IgG Western blot is positive, then CRMP-5-IgG IFA titer will be performed at an additional charge.

If the IFA pattern suggests Purkinje cytoplasmic antibody type 1 (PCA-1), then PCA-1 IB and PCA-1 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-2 antibody, then PCA-2 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-Tr antibody, then PCA-Tr IB and PCA-Tr titer will be performed at an additional charge.

If the IFA pattern suggests IgLON5 antibody, then IgLON5 CBA and IgLON5 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests GTPase regulator associated with focal adhesion kinase-1 (GRAF1) antibody, then GRAF1 CBA and GRAF1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests inositol 1,4,5-trisphosphate receptor (ITPR1) antibody, then ITPR1 CBA and ITPR1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-receptor antibody, then AMPA-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests dipeptidyl-peptidase-like protein-6 antibody (DPPX) antibody, then DPPX CBA and DPPX antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests gamma-aminobutyric acid B (GABA-B)-receptor antibody, then GABA-B-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests glial fibrillary acidic protein (GFAP) antibody, then GFAP antibody CBA and GFAP antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests metabotropic glutamate receptor 1 (mGluR1) antibody, then mGluR1 CBA and mGluR1 antibody IFA titer will be performed at an additional charge.

If N-methyl-D-aspartate (NMDA)-receptor antibody CBA is positive, then NMDA-receptor antibody IFA titer is performed at an additional charge.

If the IFA pattern suggests neuronal intermediate filament (NIF) antibody, then alpha internexin CBA, NIF heavy chain CBA, NIF light chain CBA, and NIF antibody IFA titer will be performed at an additional charge.

If the Kelch-like protein 11 (KLHL11) CBA is reactive, then KLHL11 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests neurochondrin antibody, then neurochondrin antibody CBA and neurochondrin titer will be performed at an additional charge.

If the IFA pattern suggests septin-5 antibody, then septin-5 CBA and septin-5 titer will be performed at an additional charge.

If the IFA pattern suggests septin-7 antibody, then septin-7 CBA and septin-7 titer are performed at an additional charge.

For more information see Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum.

• Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum

GRFIS, GRFTS, K11TS, AGN1S, AGNTS, AMPIS, AMPHS, APHTS, ANN1S, AN1TS, ANN2S, AN2TS, ANN3S, AN3TS, APBIS, APBTS, CRMTS, DPPIS, DPPTS, GABIS, GFAIS, GFATS, IG5IS, IG5TS, ITPIS, ITPTS, GL1IS, GL1TS, NCDIS, NCDTS, NIFIS, NIFTS, NMDIS, PCABP, PC1TS, PCAB2, PC2TS, PCATR, PCTTS, SP7IS, SP7TS, SP5IS, SP5TS: Indirect Immunofluorescence Assay (IFA)

GRFCS, K11CS, AMPCS, APBCS, CS2CS, DPPCS, GABCS, GFACS, IG5CS, ITPCS, LG1CS, GL1CS, NCDCS, AINCS, NFLCS, NFHCS, NMDCS, SP7CS, SP5CS: Cell Binding Assay (CBA)

CRMWS: Western Blot (WB)

AGNBS, AMIBS, AN1BS, AN2BS, PC1BS, PCTBS: Immunoblot (IB)

CCPQ, GD65S: Radioimmunoassay (RIA)

Ataxia

Chorea

Dyskinesias

Myoclonus

Parkinsonism

Brainstem encephalitis

If the immunofluorescence assay (IFA) patterns suggest amphiphysin antibody, then amphiphysin immunoblot (IB) and amphiphysin titer will be performed at an additional charge.

If the IFA pattern suggests antiglial nuclear antibody-1 (AGNA)-1, then AGNA-1 IB and AGNA-1 titer will be performed at an additional charge.

If the IFA pattern suggests antineuronal nuclear antibody type 1 (ANNA-1), then ANNA-1 IB, ANNA-1 titer, and ANNA-2 IB will be performed at an additional charge.

If the IFA pattern suggests ANNA-2 antibody, then ANNA-2 IB, ANNA-2 titer, and ANNA-1 IB will be performed at an additional charge.

If client requests or the IFA pattern suggests ANNA-3 antibodies, then ANNA-3 titer will be performed at an additional charge.

If the IFA pattern suggests adaptor protein 3 beta 2 (AP3B2) antibodies, then AP3B2 cell-binding assay (CBA) and AP3B2 titer will be performed at an additional charge.

If collapsin response-mediator protein-5 (CRMP-5)-IgG Western blot is positive, then CRMP-5-IgG IFA titer will be performed at an additional charge.

If the IFA pattern suggests Purkinje cytoplasmic antibody type 1 (PCA-1), then PCA-1 IB and PCA-1 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-2 antibody, then PCA-2 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-Tr antibody, then PCA-Tr IB and PCA-Tr titer will be performed at an additional charge.

If the IFA pattern suggests IgLON5 antibody, then IgLON5 CBA and IgLON5 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests GTPase regulator associated with focal adhesion kinase-1 (GRAF1) antibody, then GRAF1 CBA and GRAF1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests inositol 1,4,5-trisphosphate receptor (ITPR1) antibody, then ITPR1 CBA and ITPR1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-receptor antibody, then AMPA-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests dipeptidyl-peptidase-like protein-6 antibody (DPPX) antibody, then DPPX CBA and DPPX antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests gamma-aminobutyric acid B (GABA-B)-receptor antibody, then GABA-B-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests glial fibrillary acidic protein (GFAP) antibody, then GFAP antibody CBA and GFAP antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests metabotropic glutamate receptor 1 (mGluR1) antibody, then mGluR1 CBA and mGluR1 antibody IFA titer will be performed at an additional charge.

If N-methyl-D-aspartate (NMDA)-receptor antibody CBA is positive, then NMDA-receptor antibody IFA titer is performed at an additional charge.

If the IFA pattern suggests neuronal intermediate filament (NIF) antibody, then alpha internexin CBA, NIF heavy chain CBA, NIF light chain CBA, and NIF antibody IFA titer will be performed at an additional charge.

If the Kelch-like protein 11 (KLHL11) CBA is reactive, then KLHL11 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests neurochondrin antibody, then neurochondrin antibody CBA and neurochondrin titer will be performed at an additional charge.

If the IFA pattern suggests septin-5 antibody, then septin-5 CBA and septin-5 titer will be performed at an additional charge.

If the IFA pattern suggests septin-7 antibody, then septin-7 CBA and septin-7 titer are performed at an additional charge.

For more information see Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum.

Multiple neuroimmunology profile tests are available. See Autoimmune Neurology Antibody Matrix.

Provide the following information:

-Relevant clinical information

-Ordering provider name, phone number, mailing address, and e-mail address

Patient Preparation:

1. For optimal antibody detection, specimen collection is recommended prior to initiation of immunosuppressant medication or intravenous immunoglobulin treatment.

2. This test should not be requested for patients who have recently received radioisotopes, therapeutically or diagnostically, because of potential assay interference. The specific waiting period before specimen collection will depend on the isotope administered, the dose given, and the clearance rate in the individual patient. Specimens will be screened for radioactivity prior to analysis. Radioactive specimens received in the laboratory will be held 1 week and assayed if sufficiently decayed or canceled if radioactivity remains.

Supplies: Sarstedt 5 mL Aliquot Tube (T914)

Collection Container/Tube:

Preferred: Red top

Acceptable: Serum gel

Submission Container/Tube: Plastic vial

Specimen Volume: 4 mL

Collection Instructions: Centrifuge and aliquot serum into a plastic vial.

• Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum

If not ordering electronically, complete, print, and send a Neurology Specialty Testing Client Test Request (T732) with the specimen.

If the immunofluorescence assay (IFA) patterns suggest amphiphysin antibody, then amphiphysin immunoblot (IB) and amphiphysin titer will be performed at an additional charge.

If the IFA pattern suggests antiglial nuclear antibody-1 (AGNA)-1, then AGNA-1 IB and AGNA-1 titer will be performed at an additional charge.

If the IFA pattern suggests antineuronal nuclear antibody type 1 (ANNA-1), then ANNA-1 IB, ANNA-1 titer, and ANNA-2 IB will be performed at an additional charge.

If the IFA pattern suggests ANNA-2 antibody, then ANNA-2 IB, ANNA-2 titer, and ANNA-1 IB will be performed at an additional charge.

If client requests or the IFA pattern suggests ANNA-3 antibodies, then ANNA-3 titer will be performed at an additional charge.

If the IFA pattern suggests adaptor protein 3 beta 2 (AP3B2) antibodies, then AP3B2 cell-binding assay (CBA) and AP3B2 titer will be performed at an additional charge.

If collapsin response-mediator protein-5 (CRMP-5)-IgG Western blot is positive, then CRMP-5-IgG IFA titer will be performed at an additional charge.

If the IFA pattern suggests Purkinje cytoplasmic antibody type 1 (PCA-1), then PCA-1 IB and PCA-1 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-2 antibody, then PCA-2 titer will be performed at an additional charge.

If the IFA pattern suggests PCA-Tr antibody, then PCA-Tr IB and PCA-Tr titer will be performed at an additional charge.

If the IFA pattern suggests IgLON5 antibody, then IgLON5 CBA and IgLON5 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests GTPase regulator associated with focal adhesion kinase-1 (GRAF1) antibody, then GRAF1 CBA and GRAF1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests inositol 1,4,5-trisphosphate receptor (ITPR1) antibody, then ITPR1 CBA and ITPR1 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-receptor antibody, then AMPA-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests dipeptidyl-peptidase-like protein-6 antibody (DPPX) antibody, then DPPX CBA and DPPX antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests gamma-aminobutyric acid B (GABA-B)-receptor antibody, then GABA-B-receptor antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests glial fibrillary acidic protein (GFAP) antibody, then GFAP antibody CBA and GFAP antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests metabotropic glutamate receptor 1 (mGluR1) antibody, then mGluR1 CBA and mGluR1 antibody IFA titer will be performed at an additional charge.

If N-methyl-D-aspartate (NMDA)-receptor antibody CBA is positive, then NMDA-receptor antibody IFA titer is performed at an additional charge.

If the IFA pattern suggests neuronal intermediate filament (NIF) antibody, then alpha internexin CBA, NIF heavy chain CBA, NIF light chain CBA, and NIF antibody IFA titer will be performed at an additional charge.

If the Kelch-like protein 11 (KLHL11) CBA is reactive, then KLHL11 antibody IFA titer will be performed at an additional charge.

If the IFA pattern suggests neurochondrin antibody, then neurochondrin antibody CBA and neurochondrin titer will be performed at an additional charge.

If the IFA pattern suggests septin-5 antibody, then septin-5 CBA and septin-5 titer will be performed at an additional charge.

If the IFA pattern suggests septin-7 antibody, then septin-7 CBA and septin-7 titer are performed at an additional charge.

For more information see Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum.

Autoimmune movement disorders encapsulate a large and diverse group of neurologic disorders occurring either in isolation or accompanying more diffuse autoimmune encephalitic illnesses.

The full range of movement phenomena has been described, and, as they often occur in adults, many of the presentations can mimic neurodegenerative disorders, such as autoimmune chorea mimicking Huntington disease. Disorders may be ataxic, hypokinetic (parkinsonism), or hyperkinetic (myoclonus, chorea other dyskinetic disorders). Associated disorders may fall under the rubric of brainstem encephalitis.

The autoantibody targets are diverse and include neuronal surface proteins, such as leucine-rich, glioma-inactivated 1 (LGI1), as well as antibodies reactive with intracellular antigens (such as Purkinje cell cytoplasmic antibody type 1 [PCA-1]) that are markers of a central nervous system process mediated by CD8+ cytotoxic T cells.

In some instances (such as PCA-1 autoimmunity), antibodies detected in serum and cerebrospinal fluid can be indicative of a paraneoplastic cause and may direct the cancer search. In other instances (such as 65-kDa isoform of glutamic acid decarboxylase [GAD65] autoimmunity), a paraneoplastic cause is very unlikely, and early treatment with immunotherapy may promote improvement or recovery.

Reflex Information:

*Methodology abbreviations:

Immunofluorescence assay (IFA)

Cell-binding assay (CBA)

Western blot (WB)

Radioimmunoassay (RIA)

Immunoblot (IB)

Neuron-restricted patterns of IgG staining that do not fulfill criteria for ANNA-1, ANNA-2, ANNA-3, CRMP-5-IgG, PCA-1, PCA-2, or PCA-Tr may be reported as "unclassified anti-neuronal IgG." Complex patterns that include nonneuronal elements may be reported as "uninterpretable."

A positive antibody result is consistent with a diagnosis of an autoimmune movement disorder.

A search for cancer may be indicated, depending on the antibody profile.

A trial of immune therapy may bring about improvement in neurological symptoms.

A negative antibody test result does not exclude an autoimmune movement disorder.

Corticosteroid treatment prior to the serum collection may cause a false-negative result.

Intravenous immunoglobulin (IVIg) treatment prior to the serum collection may cause a false-positive result.

1. Honorat JA, McKeon A: Autoimmune movement disorders: a clinical and laboratory approach. Curr Neurol Neurosci Rep. 2017 Jan;17(1):4. doi: 10.1007/s11910-017-0709-2

2. Dubey D, Wilson MR, Clarkson B, et al: Expanded clinical Phenotype, oncological associations, and immunopathologic insights of paraneoplastic Kelch-like protein-11 encephalitis. JAMA Neurol. 2020 Nov 1;77(11):1420-1429. doi: 10.1001/jamaneurol.2020.2231

• Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Serum

Cell-Binding Assay

Patient specimen is applied to a composite slide containing transfected and nontransfected HEK-293 cells. After incubation and washing, fluorescein-conjugated goat-antihuman IgG is applied to detect the presence of patient IgG binding.(Package insert: IIFT: Neurology Mosaics, Instructions for the indirect immunofluorescence test. EUROIMMUN; FA_112d-1_A_UK_C13, 02/2019)

Methodology for detecting Kelch-like protein 11 (KLHL11)-IgG uses an in-house developed cell binding assay (CBA) with confirmation by a tissue indirect immunofluorescence assay (IFA). The CBA utilizes HEK293 cells that are stably transfected with DNA encoding the KLHL11 protein that has been tagged with green fluorescent protein (GFP). Since KLHL11 is localized to cytoplasmic vesicles when ectopically expressed, cells will be fixed and permeabilized prior to exposure to patient sample. Patients that are positive for KLHL11-IgG will have human IgG bound to the transfected cells. Binding will colocalize with the GFP-tagged KLHL11 protein in cytoplasmic vesicles. Patient IgG will be detected using a tetramethylrhodamine conjugated anti-human secondary antibody. The negative samples will not bind to KLHL11-GFP in transfected cells. Performed in a 96 well plate format, the plates are scanned, and images saved using the ImageXpress Micro Confocal High-Content Imaging System (Molecular Devices). Images will be scored positive or negative.(Unpublished Mayo method)

Indirect Immunofluorescence Assay

The patient's sample is tested by a standardized IFA that uses a composite frozen section of mouse cerebellum, kidney, and gut tissues. After incubation with sample and washing, fluorescein-conjugated goat-antihuman IgG is applied. Neuron-specific autoantibodies are identified by their characteristic fluorescence staining patterns. Samples that are scored positive for any neuronal nuclear or cytoplasmic autoantibody are titrated to an endpoint. Interference by coexisting non-neuron-specific autoantibodies can usually be eliminated by serologic absorption.(Honorat JA, Komorowski L, Josephs KA, et al: IgLON5 antibody: neurological accompaniments and outcomes in 20 patients. Neruol Neruoimmunol Neruoinflamm. 2017 Jul 18;4(5):e385. doi: 10.1212/NXI.0000000000000385)

Radioimmunoassay

Duplicate aliquots of the patient specimen are incubated with (125)I-labeled antigen. Immune complexes, formed by adding secondary (goat) antihuman immunoglobulin, are pelleted by centrifugation and washed. Gamma emission from the washed pellet is counted, and mean counts per minute (cpm) are compared with results yielded by high positive and negative control sera. Specimens yielding cpm higher than the background cpm yielded by normal human specimens are retested to confirm positivity and titrated as necessary to obtain a value in the linear range of the assay. The antigen binding capacity (nmol per liter) is calculated from the cpm precipitated at a dilution yielding a linear range value.(Griesmann GE, Kryzer TJ, Lennon VA: Autoantibody profiles of myasthenia gravis and Lambert-Eaton myasthenic syndrome. In: Rose NR, Hamilton RG, et al, eds. Manual of Clinical and Laboratory Immunology. 6th ed. ASM Press; 2002:1005-1012; Jones AL, Flanagan EP, Pittock SJ, et al: Responses to and outcomes of treatment of autoimmune cerebellar ataxia in adults. JAMA Neurol. 2015 Nov;72[11]:1304-1312. doi: 10.1001/jamaneurol.2015.2378)

Western Blot

Neuronal antigens extracted aqueously from adult rat cerebellum, full-length recombinant human collapsin response-mediator protein-5 (CRMP-5), or full-length recombinant human amphiphysin protein is denatured, reduced, and separated by electrophoresis on 10% polyacrylamide gel. IgG is detected autoradiographically by enhanced chemiluminescence.(Yu Z, Kryzer TJ, Griesmann GE, et al: CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Ann Neurol. 2001 February;49[2]:146-154; Dubey D, Jitprapaikulsan J, Bi H, et al: Amphiphysin-IgG autoimmune neuropathy: A recognizable clinicopathologic syndrome. Neurology. 2019 Nov 12;93[20]:e1873-e1880. doi: 10.1212/WNL.0000000000008472)

Immunoblot

All steps are performed at room temperature (18-28 degrees C) utilizing the EUROBlot One instrument. Diluted patient serum (1:101) is added to test strips (strips containing recombinant antigen manufactured and purified using biochemical methods) in individual channels and incubated for 30 minutes. Positive specimens will bind to the purified recombinant antigen and negative specimens will not bind. Strips are washed to remove unbound serum antibodies and then incubated with anti-human IgG antibodies (alkaline phosphatase-labelled) for 30 minutes. The strips are again washed to remove unbound anti-human IgG antibodies and nitroblue tetrazolium chloride/5-bromo-4-chloro-3-indolylphosphate substrate is added. Alkaline phosphatase enzyme converts the soluble substrate into a colored insoluble product on the membrane to produce a black band. Strips are digitized via picture capture on the EUROBlot One instrument and evaluated with the EUROLineScan software.(O'Connor K, Waters P, Komorowski L, et al: GABAA receptor autoimmunity: A multicenter experience. Neurol Neuroimmunol Neuroinflamm. 2019 Apr 4;6[3]:e552. doi: 10.1212/NXI.0000000000000552)

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86596

86255 x 25

84182

86341

84182 AGNBS (if appropriate)

86256 AGNTS (if appropriate)

86255 AINCS (if appropriate)

84182 AMIBS (if appropriate)

86256 AMPIS (if appropriate)

84182 AN1BS (if appropriate)

86256 AN1TS (if appropriate)

84182 AN2BS (if appropriate)

86256 AN2TS (if appropriate)

86256 AN3TS (if appropriate)

86255 APBCS (if appropriate)

86256 APBTS (if appropriate)

86256 APHTS (if appropriate)

86256 CRMTS (if appropriate)

86255 DPPCS (if appropriate)

86256 DPPTS (if appropriate)

86256 GABIS (if appropriate)

86255 GFACS (if appropriate)

86256 GFATS (if appropriate)

86255 GL1CS (if appropriate)

86256 GL1TS (if appropriate)

86255 GRFCS (if appropriate)

86256 GRFTS (if appropriate)

86255 IG5CS (if appropriate)

86256 IG5TS (if appropriate)

86255 ITPCS (if appropriate)

86256 ITPTS (if appropriate)

86256 K11TS (if appropriate)

86255 NCDCS (if appropriate)

86256 NCDTS (if appropriate)

86255 NFHCS (if appropriate)

86255 NFLCS (if appropriate)

86256 NIFTS (if appropriate)

86256 NMDIS (if appropriate)

84182 PC1BS (if appropriate)

86256 PC1TS (if appropriate)

86256 PC2TS (if appropriate)

84182 PCTBS (if appropriate)

86256 PCTTS (if appropriate)

86255 SP5CS (if appropriate)

86256 SP5TS (if appropriate)

86255 SP7CS (if appropriate)

86256 SP7TS (if appropriate)