Test Id : MDC2

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

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

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

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

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

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

If the collapsin response-mediator protein-5 (CRMP-5)-IgG Western blot is positive, then the 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 the PCA-1 IB and PCA-1 IFA titer will be performed at an additional charge.

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

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

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

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

If the gamma-aminobutyric acid B (GABA-B)-receptor CBA result is positive, then the 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 the 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 the mGluR1 CBA and mGluR1 antibody IFA titer will be performed at an additional charge.

If the N-methyl-D-aspartate (NMDA)-receptor CBA result is positive, then the NMDA-receptor 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 the GRAF1 CBA and GRAF1 antibody IFA titer will be performed at an additional charge.

If the IgLON5 antibody CBA result is positive, then the IgLON5 antibody IFA titer will be performed at an additional charge.

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

If the IFA pattern suggests neuronal intermediate filament (NIF) antibody, then the 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 result is reactive, then the KLHL11 antibody IFA titer will be performed at an additional charge.

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

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

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

If the IFA pattern suggests tripartite motif-containing protein 46 (TRIM46) antibody, then the TRIM46 antibody CBA and TRIM46 IFA titer will be performed at an additional charge.

If the IFA pattern suggests phosphodiesterase 10A (PDE10A) antibody, then the PDE10A antibody IFA titer will be performed at an additional charge.

For more information see:

Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Spinal Fluid

Central Nervous System Demyelinating Disease Diagnostic Algorithm

Multiple neurological phenotype-specific autoimmune/paraneoplastic evaluations are available. For more information as well as phenotype-specific testing options, refer to Autoimmune Neurology Test Ordering Guide.

When more than one evaluation is ordered on the same order number the duplicate will be canceled.

For a list of antibodies performed with each evaluation, 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: For optimal antibody detection, specimen collection is recommended before initiation of immunosuppressant medication, or corticosteroid or intravenous immunoglobulin (IVIg) treatment.

Container/Tube: Sterile vial

Preferred: Collection vial number 1

Acceptable: Any collection vial

Specimen Volume: 4 mL

• Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Spinal Fluid
• Central Nervous System Demyelinating Disease Diagnostic Algorithm

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

2 mL

Evaluating patients with suspected paraneoplastic or other autoimmune movement disorders including patients with ataxia, brainstem encephalitis, chorea, dyskinesias, myoclonus, and parkinsonism using spinal fluid specimens

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

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

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

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

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

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

If the collapsin response-mediator protein-5 (CRMP-5)-IgG Western blot is positive, then the 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 the PCA-1 IB and PCA-1 IFA titer will be performed at an additional charge.

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

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

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

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

If the gamma-aminobutyric acid B (GABA-B)-receptor CBA result is positive, then the 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 the 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 the mGluR1 CBA and mGluR1 antibody IFA titer will be performed at an additional charge.

If the N-methyl-D-aspartate (NMDA)-receptor CBA result is positive, then the NMDA-receptor 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 the GRAF1 CBA and GRAF1 antibody IFA titer will be performed at an additional charge.

If the IgLON5 antibody CBA result is positive, then the IgLON5 antibody IFA titer will be performed at an additional charge.

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

If the IFA pattern suggests neuronal intermediate filament (NIF) antibody, then the 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 result is reactive, then the KLHL11 antibody IFA titer will be performed at an additional charge.

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

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

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

If the IFA pattern suggests tripartite motif-containing protein 46 (TRIM46) antibody, then the TRIM46 antibody CBA and TRIM46 IFA titer will be performed at an additional charge.

If the IFA pattern suggests phosphodiesterase 10A (PDE10A) antibody, then the PDE10A antibody IFA titer will be performed at an additional charge.

For more information see:

Autoimmune/Paraneoplastic Movement Disorder Evaluation Algorithm-Spinal Fluid

Central Nervous System Demyelinating Disease Diagnostic Algorithm

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-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 cerebrospinal fluid (CSF) collection may cause a false-negative result.

Intravenous immunoglobulin treatment prior to the CSF 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;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;77(11):1420-1429. doi:10.1001/jamaneurol.2020.2231

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;4(5):e385. doi:10.1212/NXI.0000000000000385)

Radioimmunoassay:

(125)I-labeled recombinant human antigens or labeled receptors are incubated with patient specimen. After incubation, anti-human IgG is added to form an immunoprecipitate. The amount of (125)I-labeled antigen in the immunoprecipitate is measured using a gamma-counter. The amount of gamma emission in the precipitate is proportional to the amount of antigen-specific IgG in the specimen. Results are reported as units of precipitated antigen (nmol) per liter of patient sample.(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;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;49[2]:146-154; Dubey D, Jitprapaikulsan J, Bi H, et al. Amphiphysin-IgG autoimmune neuropathy: A recognizable clinicopathologic syndrome. Neurology. 2019;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 specimen (1:12.5) 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 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 produces 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;6[3]:e552 doi:10.1212/NXI.0000000000000552)

Profile tests: Monday through Sunday; Reflex tests: Varies

• Authorized users can sign in to Test Prices for detailed fee information.
• Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
• Prospective clients should contact their account representative. For assistance, contact Customer Service.

This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.

86255 x26

84182

86341

0432U

84182-AGNBC (if appropriate)

86256-GNTC (if appropriate)

86255-AINCC (if appropriate)

84182-AMIBC (if appropriate)

86256-AMPIC (if appropriate)

84182-AN1BC (if appropriate)

86256-AN1TC (if appropriate)

84182-AN2BC (if appropriate)

86256-AN2TC (if appropriate)

86256-AN3TC (if appropriate)

86255-APBCC (if appropriate)

86256-APBTC (if appropriate)

86256-APHTC (if appropriate)

86256-CRMTC (if appropriate)

86256-DPPTC (if appropriate)

86256-GABIC (if appropriate)

86255-GFACC (if appropriate)

86256-GFATC (if appropriate)

86255-GL1CC (if appropriate)

86256-GL1TC (if appropriate)

86255-GRFCC (if appropriate)

86256-GRFTC (if appropriate)

86256-IG5TC (if appropriate)

86255-ITPCC (if appropriate)

86256-ITPTC (if appropriate)

86256-K11TC (if appropriate)

86255-NCDCC (if appropriate)

86256-NCDTC (if appropriate)

86255-NFHCC (if appropriate)

86255-NFLCC (if appropriate)

86256-NIFTC (if appropriate)

86256-NMDIC (if appropriate)

84182-PC1BC (if appropriate)

86256-PC1TC (if appropriate)

86256-PC2TC (if appropriate)

84182-PCTBC (if appropriate)

86256-PCTTC (if appropriate)

86256-PDETC (if appropriate)

86255-SP5CC (if appropriate)

86256-SP5TC (if appropriate)

86255-SP7CC (if appropriate)

86256-SP7TC (if appropriate)

86255-T46CC (if appropriate)

86256-T46TC (if appropriate)