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The value of LGI1, Caspr2 and voltage-gated potassium channel antibodies in encephalitis

Nature Reviews Neurology volume 13, pages 290–301 (2017)Cite this article

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Key Points

  • Three groups of voltage-gated potassium channel (VGKC) antibody-positive patients should be distinguished: patients with antibodies against leucine-rich glioma-inactivated 1 (LGI1), patients with antibodies against contactin-associated protein-like 2 (Caspr2), and patients lacking both of these antibodies

  • Patients with anti-LGI1 antibodies usually present with typical limbic encephalitis, including alteration of memory and behaviour, spatial disorientation and several types of seizures

  • Patients with anti-Caspr2 antibodies present with various syndromes that involve the CNS and/or PNS, which mainly consist of cognitive decline, epilepsy and peripheral nerve hyperexcitability

  • Patients with antibodies against LGI1 or Caspr2 usually respond well to immunotherapy

  • The clinical relevance of antibodies against the VGKC complex that lack reactivity against LGI1 and Caspr2 is uncertain; in patients with these antibodies, clinical assessment and ancillary tests prevail for the establishment of a diagnosis and formulation of treatment

Abstract

The discovery, in 2010, of autoantibodies against the extracellular proteins LGI1 and Caspr2 facilitated a change of view regarding the clinical importance of voltage-gated potassium channel (VGKC) antibodies. Currently, these antibodies are all classified as VGKC-complex antibodies, and are commonly considered to have a similar clinical value. However, studies from the past few years show that the immune responses mediated by these antibodies have differing clinical relevance. Here, we review the clinical importance of these immune responses in three settings: patients with anti-LGI1 antibodies, patients with anti-Caspr2 antibodies, and patients with antibodies against the VGKC complex that lack LGI1 and Caspr2 specificity. Antibodies against LGI1 and Caspr2 are associated with different but well-defined syndromes, whereas the clinical importance of VGKC-complex antibodies without LGI1 and Caspr2 specificity is questionable. We describe each of these syndromes, discuss the function of the target antigens and review the limited paediatric literature on the topic. The findings emphasize the importance of defining these disorders according to the molecular identity of the targets (LGI1 or Caspr2), and caution against the use of VGKC-complex antibodies for the diagnosis and treatment of patients without further definition of the antigen.

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Figure 1: Schematic overview of the LGI1 protein in the synapse.
Figure 2: Schematic overview of the Caspr2 protein in the juxtaparanodal region of myelinated axons.
Figure 3: LGI1 and Caspr2 immunohistochemistry on rat brain.
Figure 4: Proposed therapy scheme for anti-LGI1 encephalitis.

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Authors and Affiliations

  1. Department of Neurology, Erasmus University Medical Center, 's-Gravendijkwal 230, PO Box 2040, Rotterdam, 3000CA, Netherlands

    Agnes van Sonderen & Maarten J. Titulaer

  2. Department of Neurology, Haga Hospital, Leyweg 275, The Hague, 2545CH, Netherlands

    Agnes van Sonderen

  3. Neuroimmunology Program, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), University of Barcelona, Carrer Casanova 143, Cellex P3A, Barcelona, 08036, Spain

    Mar Petit-Pedrol & Josep Dalmau

  4. Centro de Investigación Biomédica en Red (CIBER), Carrer Casanova 143, Cellex P3A, Barcelona, 08036, Spain

    Mar Petit-Pedrol & Josep Dalmau

  5. Department of Neurology, Hospital Clinic, Carrer Casanova 143, Cellex P3A, Barcelona, 08036, Spain

    Josep Dalmau

  6. Institució Catalana de Recerca i Estudis Avançats (ICREA), Carrer Casanova 143, Cellex P3A, Barcelona, 08036, Spain

    Josep Dalmau

  7. University of Pennsylvania, 3400 Spruce Street, 3 W. Gates, Philadelphia, 19104, Pennsylvania, USA

    Josep Dalmau

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All authors contributed equally to discussion of content, writing and review and editing of the manuscript before submission. A.v.S, M.P.-P. and M.J.T. researched data for the article.

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Correspondence to Maarten J. Titulaer.

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Competing interests

J.D. receives royalties from patents from Athena Diagnostics for the use of Ma2 and N-methyl-d-aspartate receptors (NMDAR) as autoantibody tests, and licensing fees from Euroimmun for a patent for the use of NMDAR as an autoantibody test. M.J.T. received research funds for serving on a scientific advisory board of MedImmune, Guidepoint Global, and a travel grant for lecturing in India from Sun Pharma, India. The other authors declare no competing interests.

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van Sonderen, A., Petit-Pedrol, M., Dalmau, J. et al. The value of LGI1, Caspr2 and voltage-gated potassium channel antibodies in encephalitis. Nat Rev Neurol 13, 290–301 (2017). https://doi.org/10.1038/nrneurol.2017.43

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