• Janev Fehmi, Alexander J Davies, Jon Walters, Timothy Lavin, Ryan Keh, Alexander M Rossor, Tudor Munteanu, Norman Delanty, Rhys Roberts, Dirk Bäumer, Graham Lennox, and Simon Rinaldi.
• Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
• J. Neurol. Neurosurg. Psychiatr. 2021 Oct 1; 92 (10): 1089-1095.

ObjectivesWe aimed to define the clinical and serological characteristics of pan-neurofascin antibody-positive patients.MethodsWe tested serum from patients with suspected immune-mediated neuropathies for antibodies directed against nodal/paranodal protein antigens using a live cell-based assay and solid-phase platform. The clinical and serological characteristics of antibody-positive and seronegative patients were then compared. Sera positive for pan-neurofascin were also tested against live myelinated human stem cell-derived sensory neurons for antibody binding.ResultsEight patients with IgG1-subclass antibodies directed against both isoforms of the nodal/paranodal cell adhesion molecule neurofascin were identified. All developed rapidly progressive tetraplegia. Cranial nerve deficits (100% vs 26%), autonomic dysfunction (75% vs 13%) and respiratory involvement (88% vs 14%) were more common than in seronegative patients. Four patients died despite treatment with one or more modalities of standard immunotherapy (intravenous immunoglobulin, steroids and/or plasmapheresis), whereas the four patients who later went on to receive the B cell-depleting therapy rituximab then began to show progressive functional improvements within weeks, became seronegative and ultimately became functionally independent.ConclusionsIgG1 pan-neurofascin antibodies define a very severe autoimmune neuropathy. We urgently recommend trials of targeted immunotherapy for this serologically classified patient group.© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

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