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Clinical, Radiologic, and Immunologic Features of Patients With CTLA4 Deficiency With Neurologic Involvement
Cyrille Coustal1, Radjiv Goulabchand1, Pierre Labauge1
1From the Department of Internal Medicine and Multi-Organic Diseases (C.C., P.G., P.R.), Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital; University of Montpellier (C.C., R.G., P.L., P.G., E. Jeziorski, X.A.); Internal Medicine Department (R.G.), CHU Nîmes; Department of Neurology (P.L., C.C.-D., X.A.), Montpellier University Hospital; INM (P.L., X.A.), INSERM; Institute of Regenerative Medicine and Biotherapy (P.G.), INSERM U1183, Montpellier; Sorbonne Université (E. Januel); Institut Pierre Louis d'Epidémiologie et de Santé Publique (E. Januel), Département de Santé Publique; Département de Neurologie (E. Januel), Hôpital Pitié Salpêtrière, AP-HP, Paris; Pediatrics Department (E. Jeziorski), Montpellier University Hospital; Department of Internal Medicine (V.S.), Amiens University Medical Center; Internal Medicine Department (J.-F.V.), Bordeaux University Hospital Centre, Hôpital Haut-Lévêque, Pessac; Clinical Immunology Department (D.B., C.F.), National Reference Center for Castleman Disease; UMR 1149 CRI INSERM (D.B.), Hôpital Saint Louis, Assistance Publique Hôpitaux de Paris (APHP); Université Paris Diderot (D.B., C.F.); Inserm U1126 (C.F.), Centre Hayem, Hôpital Saint-Louis; Internal Medicine Department (D.G.), Hôpital Saint Antoine, APHP, Paris; Pediatric Oncology Hematology Unit (N.A.), Bordeaux University Hospital; Plurithématique CIC (CICP) (N.A.), Centre d'Investigation Clinique (CIC) 1401, INSERM; Centre de Référence National des Cytopénies Autoimmunes de l'Enfant (CEREVANCE) (N.A.), Bordeaux; Department of Internal Medicine (J.G.), Saint-Nazaire Hospital; Department of Internal Medicine (M.P.-J.), Purpan University Hospital, Toulouse; Department of Hematology (F.S.), Necker-Enfants Malades University Hospital, AP-HP; INSERM UMR 1163 and CNRS ERL 8254 (F.S.), Imagine Institut; Descartes University (F.S., B.N.); Pediatric Hematology-Immunology and Rheumatology Department (B.N., N.M.), Hôpital Necker-Enfants Malades, AP-HP; Laboratory of Immunogenetics of Pediatric Autoimmunity (B.N.), INSERM UMR 1163, Imagine Institute; and French National Reference Center for Primary Immune Deficiencies (CEREDIH) (N.M.), Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
Objectives:
CTLA4 deficiency (CTLA4d) is a disease with multisystem autoimmune features, including neurologic manifestations. We aimed to describe neurologic involvement in these patients.
Methods:
We performed a cross-sectional observational study using the French Reference Centre for Primary Immunodeficiencies (CEREDIH) registry plus a surveillance in national society networks. Participants with confirmed CTLA4d and neurologic involvement were included. Clinical, laboratory, and radiologic features were collected, as well as treatments. Available MRI was double-reviewed.
Results:
Among 70 patients with CTLA4d, 13 patients (21%) had neurologic involvement. Neurologic symptoms began at a median age of 18 [15-45] years, mostly occurring after systemic manifestations (median delay: 8.5 [4.5-10.5] years). Main symptoms included headaches, focal deficit (54% each), and seizures (38%). MRI detected at least 1 large contrast-enhancing lesion in 8 patients. Lesions reminiscent of multiple sclerosis lesions were found in 6 patients. Cerebellar (6 patients) and large spinal cord lesions (3 patients) were common. Ten patients were treated with abatacept, of whom 9 (90%) showed good clinical and radiologic response.
Discussion:
Neurologic involvement is common among patients with CTLA4d. Despite its rarity, and considering the suspected efficacy of abatacept, neurologists should be aware of the characteristics of CTLA4d neurologic involvement.
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