• Ramona Miske, Madeleine Scharf, Kathrin Borowski, Ina Specht, Merle Corty, Monika-Johanna Loritz, Frederik Rombach, Guy Laureys, Nadine Rochow, Christiane Radzimski, Linda Schnitter, Dominica Ratuszny, Thomas Skripuletz, Mike P Wattjes, Stefanie Hahn, Yvonne Denno, Khadija Guerti, Matthijs Oyaert, Farid Benkhadra, Corinna Ines Bien, Sophie Nitsch, Klaus-Peter Wandinger, Vincent van Pesch, Christian Probst, Bianca Teegen, Lars Komorowski, and Kurt-Wolfram Sühs.
• Institute for Experimental Immunology, affiliated with EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560 Luebeck, Germany.
• J. Neurol. Neurosurg. Psychiatr. 2024 Apr 25.

BackgroundWe aimed to investigate the clinical, imaging and fluid biomarker characteristics in patients with antidiacylglycerol lipase alpha (DAGLA)-autoantibody-associated cerebellitis.MethodsSerum and cerebrospinal fliud (CSF) samples from four index patients were subjected to comprehensive autoantibody screening by indirect immunofluorescence assay (IIFA). Immunoprecipitation, mass spectrometry and recombinant protein assays were used to identify the autoantigen. Sera from 101 patients with various neurological symptoms and a similar tissue staining pattern as the index patient samples, and 102 healthy donors were analysed in recombinant cell-based IIFA (RC-IIFA) with the identified protein. Epitope characterisation of all positive samples was performed via ELISA, immunoblot, immunoprecipitation and RC-IIFA using different DAGLA fragments.ResultsAll index patients were relatively young (age: 18-34) and suffered from pronounced gait ataxia, dysarthria and visual impairments. Paraclinical hallmarks in early-stage disease were inflammatory CSF changes and cerebellar cortex hyperintensity in MRI. Severe cerebellar atrophy developed in three of four patients within 6 months. All patient samples showed the same unclassified IgG reactivity with the cerebellar molecular layer. DAGLA was identified as the target antigen and confirmed by competitive inhibition experiments and DAGLA-specific RC-IIFA. In RC-IIFA, serum reactivity against DAGLA was also found in 17/101 disease controls, including patients with different clinical phenotypes than the one of the index patients, and in 1/102 healthy donors. Epitope characterisation revealed that 17/18 anti-DAGLA-positive control sera reacted with a C-terminal intracellular DAGLA 583-1042 fragment, while the CSF samples of the index patients targeted a conformational epitope between amino acid 1 and 157.ConclusionsWe propose that anti-DAGLA autoantibodies detected in CSF, with a characteristic tissue IIFA pattern, represent novel biomarkers for rapidly progressive cerebellitis.© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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