Expert Review of Neurotherapeutics

ISSN: 1473-7175 (Print) 1744-8360 (Online) Journal homepage: http://www.tandfonline.com/loi/iern20

Autoimmune autonomic ganglionopathy: an

update on diagnosis and treatment

Shunya Nakane, Akihiro Mukaino, Osamu Higuchi, Mari Watari, Yasuhiro

Maeda, Makoto Yamakawa, Keiichi Nakahara, Koutaro Takamatsu, Hidenori
Matsuo & Yukio Ando

To cite this article: Shunya Nakane, Akihiro Mukaino, Osamu Higuchi, Mari Watari, Yasuhiro
Maeda, Makoto Yamakawa, Keiichi Nakahara, Koutaro Takamatsu, Hidenori Matsuo & Yukio Ando
(2018) Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment, Expert
Review of Neurotherapeutics, 18:12, 953-965, DOI: 10.1080/14737175.2018.1540304

To link to this article: https://doi.org/10.1080/14737175.2018.1540304

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Oct 2018.
Published online: 01 Nov 2018.

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EXPERT REVIEW OF NEUROTHERAPEUTICS
2018, VOL. 18, NO. 12, 953–965
https://doi.org/10.1080/14737175.2018.1540304

REVIEW

Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment

Shunya Nakanea,b, Akihiro Mukainoa,b, Osamu Higuchic, Mari Wataria, Yasuhiro Maedac, Makoto Yamakawaa,
Keiichi Nakaharaa, Koutaro Takamatsua, Hidenori Matsuoc and Yukio Andoa
a
Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; bDepartment of Molecular Neurology
and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan; cDepartment of Neurology and Clinical Research, Nagasaki Kawatana Medical
Center, Nagasaki, Japan

ABSTRACT ARTICLE HISTORY

Introduction: Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated dis- Received 9 August 2018
order that leads to autonomic failure. The disorder is associated with autoantibodies to the ganglionic Accepted 22 October 2018
nicotinic acetylcholine receptor (gAChR). We subsequently reported that AAG is associated with an KEYWORDS
overrepresentation of psychiatric symptoms, sensory disturbance, autoimmune diseases, and endocrine Ganglionic acetylcholine
disorders. receptor; autoantibodies;
Area covered: The aim of this review was to describe AAG and highlight its pivotal pathophysiological autoimmune autonomic
aspects, clinical features, laboratory examinations, and therapeutic options. ganglionopathy; extra-
Expert commentary: AAG is a complex neuroimmunological disease, these days considered as an autonomic manifestations;
autonomic failure with extra-autonomic manifestations (and various limited forms). Further comprehen- immunotherapy
sion of the pathophysiology of this disease is required, especially the mechanisms of the extra-
autonomic manifestations should be elucidated. There is the possibility that the co-presence of anti-
bodies that were directed against the other subunits in both the central and peripheral nAChRs in the
serum of the AAG patients. Some patients improve with immunotherapies such as IVIg and/or corti-
costeroid and/or plasma exchange. 123I-MIBG myocardial scintigraphy may be a useful tool to monitor
the therapeutic effects of immunotherapies.

1. Introduction preservation of somatic motor and sensory functions, Colan

and his colleagues reported the first case of acute autonomic
Autoimmune autonomic ganglionopathy (AAG; also known as
and sensory neuropathy is characterized autonomic and sen-
autoimmune autonomic neuropathy or acute pandysautono-
sory impairment without motor dysfunction that reaches its
mia) is an autoimmune disease affecting the autonomic gang-
peak severity within a short period in 1980 (Figure 1) [8].
lia, leading to various autonomic symptoms. In the
Regarding idiopathic autonomic neuropathy, three subgroups
approximately half of the cases, it is caused by autoantibodies
have been proposed on basis of the concomitance or absence
(Abs) directed against the ganglionic acetylcholine receptor
of sensory or motor dysfunctions: 1) pure autonomic neuropa-
(gAChR) [1–3].
thy (=APD), 2) autonomic neuropathy with sensory impairment
AAG is a relatively recently described neurological disease.
(AASN), and 3) autonomic neuropathy with sensory and motor
One of the earliest descriptions of a patient who had pure
impairment (AASMN), although there could be some overlap
pandysautonomia was by Young and colleagues in 1969
[9,10]. Fagius et al reported the case of autonomic and sensory
(Figure 1) [4]. Thereafter, some patients with acute pandysau-
neuropathy demonstrated sensory ataxia, and the autopsy of
tonomia (APD) have since been reported. In 1975, Young and
this case revealed the dorsal root ganglia showed very severe
colleagues published the full description of their original
damage with only a few remaining neurons [11]. In this period,
patient and considered the diagnostic criteria [5]. During this
idiopathic autonomic neuropathy including APD, AASN, and
period, most patients with APD have been report to show acute
AASMN categorized acute idiopathic inflammatory neuropa-
or subacute progression with antecedent events (possibly infec-
thies, and positioned at one end of the spectrum of GBS.
tion illness), widespread autonomic failure, and monophasic
However, Hainfellner et al described an autopsy case of AASN,
clinical course [6,7]. The causes of APD were unknown at this
and they showed widespread inflammation of sensory and
time, however, and immunological mechanism similar to
autonomic ganglia with immunocytochemical evidence of a
Guillain-Barré syndrome (GBS). The site of damage in APD was
CD8 T cell-mediated cytotoxic attack against ganglion neurons
postganglionic in almost cases, but the etiological factor
[12]. And finally, Vernino and his colleagues discovered the Abs
remained unclear in the pathomechanism of APD [7].
against the neuronal gAChRs, and they proposed nicotinic acet-
Although APD was characterized by severe sympathetic and
ylcholine receptors (AChRs) autoimmunity cause dysautonomia
parasympathetic impairment with relative or complete
[1,2]. Recently, we elucidated the prevalence of extra-

CONTACT Shunya Nakane nakaneshunya@gmail.com Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo,
Chuouku, Kumamoto-shi, Kumamoto 860-8556, Japan
© 2018 Informa UK Limited, trading as Taylor & Francis Group
954 S. NAKANE ET AL.
Figure 1. Timeline | clinical, physiological and immunological developments in autoimmune dysautonomia research in early days.
autonomic manifestations in patients with AAG [13]. The pre-
sent review summarizes current status of diagnosis and treat-
ments in AAG.
2. Autonomic ganglia and acetylcholine receptor
antibodies
2.1. Nicotinic acetylcholine receptors
Neuronal nicotinic acetylcholine receptors (nAChRs) are
ligand-gated cation channels that are activated by the
endogenous acetylcholine (ACh) and the exogenous tertiary
alkaloid nicotine [14]. Each nAChR contains four transmem-
brane domains (M1-M4), an extracellular amino – and carboxy-
terminus, and a prominent M3-M4 intracellular loop of vari-
able length (Figure 2(a)) [15]. The majority of high affinity
nAChRs are heteromeric and consist of α and β subunits
(Figure 2(b)). Homomeric receptors consist of α subunits only
and usually have low affinity for agonist (Figure 2(b)). Every
nAChR is formed by the association of five subunits of which
at least two are α subunits [16,17]. Ref On autonomic neurons,
AChRs are typically composed of two α3 subunits in
 EXPERT REVIEW OF NEUROTHERAPEUTICS 955

Figure 2. Neuronal nAChR structure.

(a) Membrane topology of a nAChR subunitEach nAChR gene encodes a protein subunit consisting of a large amino-terminal extracellular domain composed of β-strands, four trans-
membrane α-helices segments (M1-M4), a variable intracellular loop between M3 and M4, and an extracellular carboxy-terminus.(b) Heteromeric and homomeric nAChRsFive subunits co-
assemble to form a functional subunit. The majority of high affinity nAChRs are heteromeric and consist of a combination of α and β subunits. Importantly, multiple α subunits may co-
assemble with multiple β subunits in the pentameric nAChR complex. Homopentameric receptors consist of α subunits only and usually have low affinity for agonist. To date, only
mammalian α7, α9, and α10 subunits may form functional homomers. Ach-binding sites are depicted as red circles.

combination with three other AChR subunits [18]. The α sub-
unit contains important binding sites for acetylcholine.
Transgenic mice lacking the α3 subunit have profound auto-
nomic failure with prominent bladder distention, gastrointest-
inal (GI) dysmotility, and lack of pupillary light reflexes
indicating that the α3 subunit is required for ganglionic neu-
rotransmission [19]. Although neurons of the autonomic gang-
lia can express numerous neuronal AChR subunits, including
α3, α4, α5, α7, β2, and β4, the properties of the AChR at
mammalian ganglionic synapses are most similar to AChRs
that are formed by α3 and β4 subunits [20,21].
The autonomic nervous system has a unique anatomic
structure (Figure 3). Unlike the somatic motor and sensory
systems, the autonomic system is composed of groups of
neurons (ganglia) with extensive synaptic connections outside
the central nervous system (CNS). Like the somatic motor
nerves, peripheral autonomic nerves originate with cholinergic
motor neurons in the brainstem and spinal cord that project
to the periphery [3]. These preganglionic nerves synapse with
neurons in autonomic ganglia. The peripheral autonomic neu-
rons, especially in the case of the intrinsic enteric autonomic
nervous system, also synapse extensively with each other. Fast
synaptic transmission within autonomic ganglia is mediated
by acetylcholine acting on nAChRs. The gAChR mediates fast
synaptic transmission in all ganglia (sympathetic, parasympa-
thetic, and enteric ganglia) in the peripheral autonomic ner-
vous system.
2.2. Ganglionic acetylcholine receptor antibodies
AAG is associated, at least in part, with Abs to the gAChR.
Antibodies to the gAChR are found in the serum of approxi-
mately 50% of patients with the acute or subacute form of
AAG in concentrations that correlate with disease severity
and have been shown to be pathogenic [2,22]. Several stu-
dies have reported that these Abs induce the internalization
of cell-surface nicotinic gAChRs and thereby impair synaptic
transmission (Figure 3) [23,24]. Although these antibodies are
useful serological markers for AAG, they are still not univer-
sally detected. Mayo clinic group reported patients with high
levels of ganglionic AChR antibodies usually have a subacute
956 S. NAKANE ET AL.
Figure 3. Autonomic nervous system and the anti-gAChR Abs.
The autonomic ganglia receive input from cholinergic motor neurons in the brainstem or
spinal cord. Fast ganglionic synaptic transmission is mediated by acetylcholine acting on
neuronal nicotinic acetylcholine receptors. The postganglionic fibers extend to innervate
numerous target organs (a few examples are shown) and release acetylcholine acting on
muscarinic receptors (m) or norepinephrine acting on alpha and beta adrenergic receptors.
The anti-gAChR Abs have the potential to physiologically block the ganglionic synaptic
transmission in both of the sympathetic and parasympathetic nervous system.
onset of disabling symptoms over a few weeks followed by
spontaneous but incomplete recovery. Patients with lower
antibody levels may have a chronic insidious presentation or
milder, limited forms of autonomic failure. Higher ganglionic
AChR antibody levels correlate with greater clinical severity
and with greater severity of laboratory measures of auto-
nomic failure. In some cases, patients treated with plasma
exchange or other immunomodulatory treatments to reduce
antibody levels can show dramatic improvement in auto-
nomic function. Additionally, in vitro studies show that
serum immunoglobulin G (IgG) isolated from patients with
AAG reduces whole-cell neuronal AChR current in cultured
human IMR-32 cells [1,2,22]. Lennon et al. developed an
experimental AAG (EAAG) by immunizing rabbits with a
recombinant neuronal AChR α3 subunit fusion protein [24].
These clinical and experimental findings indicate that the
gAChR antibodies in patients with AAG cause physiologic
changes in ganglionic AChR function and confirm that AAG
is an antibody-mediated disorder.
2.3. Detection of autoantibodies
Since the gAChR was identified as an autoantigen that is
associated with the pathogenesis of AAG, it has been a
challenge to search for gAChR-specific Abs. The radioim-
munoprecipitation assay (RIPA) and cell-based assays have
been available for the detection of Abs to the gAChR in
the sera of patients with AAG [1,2]. In Japan, cases of
idiopathic pure autonomic neuropathy have been reported
since 1975, and 29 cases of AAG have been reported [7,25].
However, no assays that detect the Abs to gAChR are
available in Japan, and this has caused difficulty in the
diagnosis of AAG. Furthermore, antibodies to non-α3 sub-
units, including the β4 gAChR subunit, have not been
identified in AAG to date. We attempted to develop a
novel technique to detect the subunit-specific antibodies
of gAChR without the use of a radioisotope. The RIPA is a
very useful tool for obtaining information about the total
amount of antibodies to gAChR [1,2].
We established luciferase immunoprecipitation systems
(LIPS) using GL8990 that can detect antibodies that bind to
the α3 or β4 gAChR subunits with high sensitivity (Figure 4)
[26]. The RIPA using [125I]-labeled epibatidine has been used
as a convenient method to detect Abs to the gAChR [1–3].
LIPS is a diagnostic technique for the serological testing of
antibodies that are associated with many different human
pathogens, is suitable for detecting an antibody against each
subunit [27–30]. We need to compare the performance of
gAChR Abs assays in clinical service.
To provide higher performance on the LIPS, we selected a
Gaussia luciferase (GL) mutant, called GL8990, for use in this
study. GL is the smallest marine luciferase that has been
discovered [31]. GL generates a greater signal intensity from
cells in culture (1000-fold) compared with the Renilla luciferase
[32]. GL8990 (featuring a phenylalanine-to-tryptophan substitu-
tion at residue 89 and a isoleucine-to-leucine substitution at
residue 90) is a GL mutant that is generated by site-directed
mutagenesis and emits bioluminescence that is 10 times
stronger and/or prolonged than intact GL [33]. We performed
the LIPS with the α3 or β4 gAChR subunit fused to a luciferase
to detect the respective Abs in human sera.
LIPS is a user-friendly assay to examine a protein–protein
interaction as described elsewhere [27–29]. The luminometer
output was measured in relative luminescence units (RLU).
Based on the data for anti-gAChRα3 and β4 Abs from the
73 HC, the cut-off values were calculated as the mean plus
three standard deviations from the mean (SD). In this study,
the antibody levels were expressed as an antibody index (A.I.)
that was calculated as follows: A.I. = [measurement value of
the sample serum (RLU)]/[the cut-off value (RLU)]. The normal
value that was established in this study from healthy indivi-
duals was <1.0 A.I. As such, serum samples with an A.I. ≥1.0
were considered positive for the relevant antibody. To eval-
uate the diagnostic accuracy of this assay, we verified the
cut-off points for all data collected in the previous study. Cut-
off points for sensitivity and specificity as well as receiver
operator characteristic (ROC) curves were obtained [34,35].
According to the ROC curves, we confirmed the most discri-
minative cut-off points, and calculated their sensitivity, spe-
cificity, and positive and negative predictive values (PPV and
NPV). The area under the curve (AUC) was 0.935 (95% con-
fidence interval [CI]: 0.897–0.972) for the LIPS assay of the
anti-gAChRα3 antibody. With the anti-gAChRα3 antibody cut-
off point of 1.0, the sensitivity and specificity values were
50.0% (95% CI: 35.2%–64.8%) and 100.0% (95% CI: 92.5%–
100.0%), respectively, while those for PPV and NPV were
100.0% and 66.7%, respectively. The AUC was 0.830 (95%
CI: 0.040–0.907) for the LIPS assay of the anti-gAChRβ4 anti-
body. With the anti-gAChRβ4 antibody cut-off point of 1.0,
the sensitivity and specificity values were 10.0% (95% CI:
3.5%–23.8%) and 100.0% (95% CI: 92.5%–100.0%), respec-
tively, while those for PPV and NPV were 100.0% and
52.84%, respectively.

Figure 4. Detection of the anti-gAChR Abs by LIPS.
The anti-gAChR Abs are detected by LIPS we developed. For the gAChR Abs LIPS assay, HEK293 cells were transfected with an expression plasmid for the gAChRα3 or β4-GL reporter. The
soluble fractionated component from the solubilized HEK 293F cells, including the gAChRα3- or β4-GL, reacted with human serum, and the specific luciferase activities of the gAChRα3- or
β4-GL were found with the luminometer. The in vitro LIPS assay can quantitatively evaluate an interaction between an antigen and an antibody with high sensitivity and without a
radioisotope.
Ching et al. have reported using the LIPS method to detect a
specific autoantibody of the AChRα1 subunit in patients with
myasthenia gravis [36]. Myasthenia gravis (MG) is an autoim-
mune channelopathy that is caused by Abs to AChRs located in
the neuromuscular junction. In about 80% of the patient sera,
these Abs to the muscle-type of the nAChR are detected [37].
The muscle nAChR is a pentamer that is composed of four
subunits (α1, β1, γ or δ, and ε). Ching et al have demonstrated
that using the α1 AChR subunit fused to Renilla luciferase in LIPS
was partly useful for the detection of Abs against each AChR
subunit. The LIPS provides a new approach to serological testing
for antibodies associated with many different human pathogens
in neuroimmunological diseases. The LIPS is based on the fusion
of protein antigens to a light-emitting enzyme reporter, Gaussia
luciferase, and then the use of these antigen fusions in immu-
noprecipitation assays with serum samples and protein
G-sepharose. After the protein G-sepharose is washed, the
level of light production is measured, yielding highly quantita-
tive antibody levels. Taken together, these reports suggest that
autoantibody detection by the LIPS will be useful for enhancing
the clinical management of autoimmune diseases.
3. Clinical features of autoimmune autonomic
ganglionopathy
3.1. Antecedent events and clinical course
So far, Hayashi et al reported the patients with AAG in Japan
were younger and more male-predominant than those in
EXPERT REVIEW OF NEUROTHERAPEUTICS 957
Western countries [25]. We extensively reviewed the histories
and ongoing clinical and laboratory evaluations of 80
Japanese patients (mean age: 60 ± 18 years old; 43 males
and 37 females) who had been diagnosed with AAG and
measured their levels of antibodies to gAChR with the LIPS
[13]. All of the patients with AAG had dysfunction in at least
one autonomic domain, and they underwent a baseline
assessment, which included a determination of the gAChR
α3 and β4 antibody levels. Moreover, we investigated based
on our specific questionnaire. Our questionnaire consisted of
six domains, addressing the following aspects: 1) age, sex,
clinical diagnosis, age at onset, symptom onset, and antece-
dent infection, 2) widespread autonomic manifestations, 3)
extra-autonomic manifestations (sensory disturbance, motor
symptoms, DTR, gait, and other neurological findings), 4)
comorbid diseases (endocrine disorders, tumor, and autoim-
mune disorders), 5) autonomic testing and MIBG scintigraphy,
and 6) other laboratory findings (CSF, and other Abs testing).
Subacute onset was defined as reaching peak autonomic
failure within 3 months, and gradual was defined as reaching
the peak level of autonomic failure within 3 months. The
patterns of mode were divided into subacute and gradual
groups, according to the duration to the peak of autonomic
symptoms. Gradual onset was more common in the seroposi-
tive AAG patients (62/80, 78%). An antecedent event (e. g.
enterocolitis, flu-like symptom, and etc.) was reported in 13
patients (16%) shortly before the initiation of autonomic
symptoms. Seven patients (7/62, 11%) had an antecedent
event in this chronic AAG group, in contrast, six patients (6/
958 S. NAKANE ET AL.

18, 33%) had an antecedent event in the subacute AAG group. 3.3. Extra-autonomic manifestations
Therefore, an antecedent event may be associated with the
Totally, 67 patients (84%) exhibited extra-autonomic manifesta-
subacute form of AAG.
tions in our recent study [13]. Extra-autonomic manifestations
consisted of sensory disturbance, CNS involvements, endocrine
disorders, autoimmune diseases, and tumors (Figure 5).
3.2. Autonomic manifestations In our questionnaire, we classified sensory disturbance into
four symptoms (paresthesia, dysesthesia, NCS abnormality,
We inquired about the presence or absence of each of the
and no symptoms). In the recent study, we detected dysesthe-
following functions that are controlled by the autonomic sys-
sia (=numbness) and superficial sensory disturbance in 37/80
tem: syncope or orthostatic hypotension for orthostatic intol-
patients with AAG (46%) [13]. Sensory examinations were
erance; sicca complex, dryness of the skin, or hypohidrosis/
performed for pinprick, temperature, light touch, vibratory
anhidrosis for heat intolerance; pupillary dysfunction; diarrhea
sensation, and joint position sensation. In 80 AAG patients,
or constipation for dysfunction of the GI system; dysuria or
abnormal motor conduction velocity, distal latency, or com-
urinary retention needing catheterization for bladder dysfunc-
pound muscle action potential values in nerve conduction
tion; and sexual dysfunction [13,26].
studies were not detected. They complained of subjective
Autonomic manifestations were various and widespread
numbness as an extra autonomic symptom, and the numb-
and they affected both sympathetic and parasympathetic
ness might have been caused by extensive disturbance of the
functions; however, orthostatic hypotension and lower (GI)
sympathetic and parasympathetic nervous system. However,
tract dysfunction were frequently observed [13]. Orthostatic
this important symptom may distinguish AAG from other dis-
hypotension for orthostatic intolerance and lower GI tract
orders such as AASN, GBS, and chronic inflammatory demye-
symptoms was observed in 64/80 patients (80%) and 59/80
linating polyneuropathy (CIDP). A nerve conduction study
patients (74%), respectively. Upper and lower GI tract symp-
could be performed to assess this, and a nerve and skin biopsy
toms were composed of various digestive system problems,
may be necessary in the patient with AAG.
such as early satiety, vomiting, abdominal pain, anorexia, diar-
In regard to CNS involvement, if any CNS (cerebral, cere-
rhea, ileus, alternate stool abnormality, taste impairment, and
bellar, brain stem, and spinal cord) symptoms were detected,
constipation. Pupillary dysfunction was observed in 21/80
we defined ‘CNS involvement’ after careful thought about
patients (26%), including two patients who had Adie’s tonic
neurodegenerative diseases. We distinguished CNS involve-
pupil. The initial symptoms of seropositive AAG in 50/80
ment from other neurological disorders including Parkinson’s
patients (62.5%) were orthostatic hypotension and/or intoler-
disease, multiple system atrophy, based on clinical assess-
ance, involving lightheadedness, orthostatic intolerance, or
ment, laboratory tests, and imaging studies. Of the 29
syncope.
Japanese patients previously reported by Hayashi et al., 12

Figure 5. The anti-gAChR Abs in AAG and related syndromes.

AAG is a clinical entity with a broad spectrum that has etiological correlations with gAChR Abs. Some of the cases with seropositive AAG have the underlying diseases. We observed that
brain involvement, sensory disturbances, and endocrine disorders were common among seropositive patients with AAG.

(41.4%) had psychiatric symptoms [25]. In our study, psychia-
tric symptoms involved depressive state (n = 2), cognitive
impairment (n = 6), apathy (n = 3), and character change
(n = 11), such as emotional instability and infantilization after
the onset of autonomic symptoms. We are considering
whether these brain symptoms and AAG can coexist based
on autoimmune etiology against both peripheral and central
nAChRs [38–40].
Totally, 11 patients (14%) exhibited the following endocrine
disorders: amenorrhea (n = 5), syndrome of inappropriate
antidiuretic hormone secretion (SIADH) (n = 2), hyponatremia
(n = 3), adrenal insufficiency (n = 1) and panhypopituitarism
(n = 1). Several Japanese neurologists have already reported
cases of APD or acute autonomic and sensory neuropathy with
amenorrhea and/or SIADH [41–43]. They have suggested that
patients with autonomic neuropathy might have both periph-
eral and CNS manifestations. nAChRs are associated with cho-
linergic neurotransmission, modulation of dopamine function,
inflammation, and activity of the hypothalamic-pituitary-adre-
nal axis [44,45]. We presumed that nAChRs are involved in a
variety of neurological systems that are implicated in the
pathophysiology of CNS involvement including endocrine dis-
orders and psychiatric symptoms.
In total, 25 patients (31%) were presented with autoim-
mune diseases, and Sjögren’s syndrome was confirmed in
nine patients. Other patients presented the other following
autoimmune diseases: systemic lupus erythematosus, rheuma-
toid arthritis, systemic sclerosis, polymyalgia rheumatica, pri-
mary biliary cirrhosis, Still’s disease, Hashimoto’s disease,
Graves’ disease, and fibromyalgia. Tumors were observed in
11 patients (14%), four of which were ovarian tumors. Small
cell lung cancer, gastric cancer, and maxillary cancer were
detected in other patients.
As mentioned above, over 80% of seropositive AAG
patients demonstrated dysautonomia with non-autonomic
findings. McKeon and his colleagues in Mayo Clinic analyzed
the clinical utility of gAChRα3 autoantibody as a marker of
neurological autoimmunity and cancer. They reviewed the
oncological associations, neurological manifestations, and
accompanying Abs in 78 gAChRα3 Abs seropositive patients
by titer [46]. We will analyze the extra-autonomic manifesta-
tions in the Japanese AAG patients by the levels of gAChRα3
and β4 Abs.
4. Atypical cases of autoimmune autonomic
ganglionopathy
4.1. Seronegative autoimmune autonomic
ganglionopathy
Sandroni and her colleagues compared the clinical character-
istics between seropositive and seronegative patients with
idiopathic autonomic neuropathy [47]. A subacute mode of
onset was more common in the group of the seropositive
patients, and the seropositive group had a significant over-
representation of pupillary abnormalities, sicca complex, and
lower GI tract dysfunction. Thereafter, they studied six
patients, four with seropositive and two with seronegative
putative AAG, and reported immunomodulatory treatment
EXPERT REVIEW OF NEUROTHERAPEUTICS 959
including intravenous immunoglobulin (IVIg), plasma
exchange (PE), and immunosuppressants can be effective in
both groups [48]. However, consideration regarding the ser-
onegative autoimmune autonomic neuropathy recently
reported. Golden et al. reported six patients presented with
subacute autonomic failure, seronegative for gAChR Abs [49].
Although three patients responded to intravenous steroids,
other immunotherapy with PE, IVIg, and rituximab was inef-
fective in all cases. They described this seronegative autoim-
mune autonomic neuropathy is characterized by prominent
sympathetic failure and sensory symptoms. Therefore, they
defined it as a new distinct clinical entity. Clarifying the patho-
mechanism of seronegative AAG is expected in the future.
4.2. Limited form of autoimmune autonomic
ganglionopathy
4.2.1. Postural orthostatic tachycardia syndrome
The spectrum of AAG continues to expand. It is known that
classic AAG phenotype presents with severe and widespread
autonomic dysfunction, and limited forms of autonomic
neuropathy, too, are being found [47]. Postural orthostatic
tachycardia syndrome (POTS) is the most common form and
orthostatic intolerance without associated orthostatic hypo-
tension, and GI disturbances are common and prolonged in
patients with POTS [50–52]. An autoimmune mechanism has
been suggested as a causal mechanism in POTS [53,54], and
antibodies such as Abs against cardiac lipid raft-associated
protein and α1AR, β1AR and β2AR agonistic Abs are present
in the serum of the patients with POTS [55–61]. More spe-
cifically, gAChR Abs are detected in the serum from the
patients with POTS. It has been indicated the detection of
gAChR Abs in 10 to 20% of POTS patients [62]. In our recent
study, we analyzed the serum of 34 patients with POTS, who
were a median of 22 years old. We found gAChR Abs in 10
(eight with gAChRα3 Abs and two with gAChRβ4 Abs), or
29% of them. The seropositive POTS patients were an aver-
age of 29 years old, compared with an average age of
20 years old for those who were negative (p = 0.012).
Here, 60% of patients who were seropositive had complica-
tions from autoimmune diseases compared with 8% in the
seronegative group (p < 0.001) [62]. We acknowledged that
the majority of seropositive patients did not have high levels
of the antibodies. Therefore, increased expression of Abs to
gAChR subunits may contribute to secondary autoimmune
responses to anti-ganglionic neuron damage in seropositive
patients. We can conclude at present we have no definite
evidence gAChR Abs has a pathogenic role in POTS, but we
will look at the relationship between the gAChR Abs and
immunotherapy outcomes for each subcategory of POTS –
neuropathic, hyperadrenergic, volume dysregulation, and
physical deconditioning.
4.2.2. Anhidrosis
Chronic anhidrosis, especially acquired idiopathic generalized
anhidrosis (AIGA), is characterized by an acquired impairment
in total body sweating despite exposure to heat or exercise.
Most cases of AIGA have been reported in Asia, particularly in
Japan [63]. Asahina and his colleagues attempted to find the
960 S. NAKANE ET AL.
Abs against muscarinic M3 receptors (M3Rs) on ecrine glands,
but anti-M3R Abs were detected in 1/12 patients (8%) with
AIGA [64]. Chronic anhidrosis may be heterogeneous. We
experienced several patients with seropositive AAG associated
with severe anhidrosis (Figure 5) [65,66]. Severe anhidrosis
came to the front in the clinical manifestations of these
cases. We should be alert to severe anhidrosis in the cases of
AAG because AAG itself is rare. We should pay attention to
autonomic function except for the sudomotor activity.
4.2.3. Gastrointestinal dysmotility
In 2008, autoimmune GI dysmotility (AGID) was proposed
new clinical entity that is a limited manifestation of auto-
immune dysautonomia and can occur as an idiopathic or
paraneoplastic phenomenon [67,68]. The presentation may
be gastroparesis, colonic inertia, or intestinal pseudoobstruc-
tion; rare cases have presented with pyloric obstruction or
anal spasm [69–73]. Several neural autoantibody specificities
aid the diagnosis of AGID: gAChRα3, voltage gated neuronal
potassium channel-complex, and calcium channel antibodies
(N type >P/Q type), muscle nAChR, striational, glutamic acid
decarboxylase 65, and peripherin [67–73]. We determined
the associations among autonomic dysfunction, anti-gAChR
Abs, and clinical features in Japanese patients with GI moti-
lity disorders including achalasia and chronic intestinal
pseudo-obstruction (CIPO) [74]. We identified 10/123 (8.1%)
patients with seropositive AAG who presented with achala-
sia, or gastroparesis, or paralytic ileus (Figure 5). Moreover,
we detected anti-gAChR Abs in 21.4% of the achalasia
patients, and in 50.0% of the CIPO patients. Although
patients with achalasia and CIPO demonstrated widespread
autonomic dysfunction, bladder dysfunction was observed in
the seropositive patients with CIPO as a prominent clinical
characteristic of dysautonomia. A prospective, multi-center,
clinical interventional study will be necessary to confirm the
relationships among the levels of anti-gAChR Abs, auto-
nomic function including severity of GI dysmotility, and the
outcome of immunotherapies.
5. Laboratory evaluations
The diagnosis of AAG requires the seropositivity for the gAChR
Abs. Furthermore, we should widely evaluate the autonomic
function in the patients with AAG. Each patient will undergo
autonomic testing, which involved, head-up tilt test, measure-
ment of the coefficient of variation in R-R intervals (CVR-R),
noradrenaline (NA) infusion test, pupillary response to local
instillation, assessment of the plasma levels of catecholamines,
sweat testing, quantitative sudomotor axon reflex test
(QSART), [123I] meta-iodobenzylguanidine (123I-MIBG) myocar-
dial scintigraphy, Valsalva maneuver, skin biopsy, GI motility
study, urodynamic study and cystometry.
Goldstein et al. report tried to differentiate AAG from pure
autonomic failure (PAF), because some part of AAG and PAF
are same chronic forms of autonomic failure [75]. AAG often
has a chronic progressive course that may resemble degen-
erative forms of autonomic failure such as PAF. Both disorders
feature low plasma levels of catecholamines during supine
rest, but plasma levels of the other endogenous catechols,
dihydroxyphenylalanine, dihydroxyphenylacetic acid, and
dihydroxyphenylglyco seem to be lower in PAF than in AAG.
In this article, they report results of QSART, Valsalva maneuver,
head-up tilt test, and 6-[18F] fluorodopamine PET scanning
besides the measurement of plasma catechols, in patients
with AAG, PAF, and two other forms of chronic autonomic
failure manifesting with OH – multiple system atrophy (MSA)
and Parkinson’s disease with neurogenic OH (PD with NOH)
[75]. Baroreflex – cardiovagal gain, calculated from the slope
of the line of best fit for the relationship between interbeat
interval and systolic blood pressure during Phase II of the
Valsalva maneuver, was also low in all four groups. QSART
responses were remarkably subnormal in AAG patients.
Conversely, QSART responses were often within the normal
range three patient groups in the three patient groups. 6-[18F]
fluorodopamine-derived radioactivity in the interventricular
septum was normal in the AAG and MSA groups and low in
the PAF and PD with NOH groups.
Gorson et al. reported the skin biopsy findings in a cohort
of patients with features suggestive of a non-length-depen-
dent small fiber neuropathy or ganglionopathy [76]. Skin
biopsy may help to differentiate between the length depen-
dent neuropathy and ganglionopathy because axonal neuro-
pathies are characterized by a retrograde nerve degeneration
with a preferential loss of fibers at the distal site [77].
123
I-MIBG, an analog of noradrenaline, is used to trace
uptake and transport both in noradrenaline presynaptic sym-
pathetic nerve terminals and in subsequent vesicular storage
[78]. Postganglionic presynaptic cardiac sympathetic nerve
endings can be noninvasively assessed by MIBG scintigraphy
because a reduction in cardiac MIBG uptake (H/M ratio) indi-
cates postganglionic sympathetic dysfunction. Cardiac MIBG
uptake is reduced in patients with Lewy body diseases such as
Parkinson’s disease and dementia with Lewy bodies [79,80]. In
the standard procedure, the H/M ratio is calculated from early
and delayed anterior chest planar images by drawing a region
of interest including the heart (H) and the other one over the
upper mediastinum (M). In our experience, the H/M ratio
during the early and delayed phases of 123I-MIBG myocardial
scintigraphy decreased by approximately 80% in AAG patients.
Decreased cardiac uptake occurred in most seropositive cases,
which indicated that 123I-MIBG myocardial scintigraphy may
be a useful tool for monitoring AAG [26].
The site of damage in AAG was analyzed by several auto-
nomic testings. Kimpinski et al. characterized the unique sudo-
motor dysfunction in AAG as widespread, predominantly
postganglionic, and a result of lesions at both the ganglia
and distal axon [81]. Manganelli et al. have also demonstrated
in a sudomotor function study and skin biopsy findings, that
there is postganglionic autonomic damage in patients with
AAG [82]. They attributed this damage to prolonged and
severe impairment of synaptic transmission. These reports
coincide with our deduction that the anatomic pattern of
autonomic dysfunction was predominantly postganglionic.
And, we have some important matters. In some of the AAG
cases, we found the other autoimmune disorders as comorbid
diseases. Although AAG and other autoimmune diseases can
coexist due to the same background of autoimmunity, few
reports have referred to anti-gAChR Abs in the autoimmune

rheumatic disorders [34,35,83]. We believe it is important to
clarify the clinical and immunological characteristics of the
coexistence of AAG and the other autoimmune disorders
(Figure 5). Thus, we should consider the comorbid diseases
(endocrine disorders, tumor, and autoimmune disorders) in
the patients with AAG as the extra-autonomic manifestations
described above.
6. Treatments
AAG treatments have so far primarily targeted symptoms,
and the treatments were helpful in most cases. Some
patients with seropositive AAG responded to treatment
with steroid pulse therapy, plasmapheresis, or IVIg, and
most of these required combined or subsequent treatments
to maintain the improvement [47,84–86]. The more severely
affected patients who did not respond to steroid pulse
therapy or PP monotherapy benefited from combined ther-
apy with other first-line therapy and immunosuppressant
agents, such as prednisolone, azathioprine, mycophenolate
mofetil, and rituximab [87]. They also required prolonged
immunotherapy for sustained clinical improvement.
However, reports of immunomodulatory therapies for AAG
are limited to small and uncontrolled case studies, and the
optimal therapy remains uncertain. When we read the past
reports, we realized the outcomes of the immunotherapies
showed the differences among individual cases and case
series. It is unclear which immunotherapy combination or
which order of the various immunotherapies will be best for
treating autonomic and extra-autonomic manifestations
of AAG.
One Japanese AAG patient has been successfully treated by
combined immunomodulatory therapies [88]. Although he
showed marked recovery of his dysautonomia after steroid
therapy, stepwise recovery of his plasma noradrenaline levels
after each treatment showed that his dramatic improvement
was not only as a result of steroid therapy. The gAChRα3 Abs
in his serum returned to the initial levels observed before
steroid administration, and the levels of the gAChRα3 Abs
were not always parallel to the clinical severity and plasma
noradrenaline levels. In previous reports, higher gChR Abs
levels correlate with greater clinical severity and with greater
severity of laboratory measures of autonomic failure. In some
cases, patients treated with plasma exchange or other immu-
nomodulatory treatments to reduce antibody levels can show
dramatic improvement in autonomic function. There is the
possibility that gAChR Ab levels did not always correlate with
the clinical course in each individual from our experience.
Combined immunotherapies are beneficial in AAG, but inter-
national multicenter collaboration is required to clarify the
correlations among the levels of anti-gAChR Abs, severity of
the autonomic and extra-autonomic manifestations, and the
outcome of the different immunotherapies.
There have been no trials of symptomatic treatment for
AAG, although it has been frequently performed on the clin-
ical spot for medical treatments. Vernino and his colleagues
attempted to develop the acetylcholinesterase inhibitor such
as pyridostigmine for AAG as a potential specific therapeutic
strategy [18]. They focused on the ganglionic synaptic
EXPERT REVIEW OF NEUROTHERAPEUTICS 961
transmission is a common pathway for all autonomic traffic,
and aimed to enhance the autonomic function through inhibi-
tion of acetylcholinesterase. Previous trials for neurogenic OH
reported midodrine and droxidopa are efficacious and safe in
the treatment [89,90]. A combination treatment for various
autonomic symptoms is often required as well as combined
immunomodulatory therapies.
7. Expert commentary
AAG is a clinical entity with a broad spectrum that has etiolo-
gical correlations with gAChR Abs. The gAChR Abs have the
potential to impair autonomic ganglionic synaptic transmis-
sion; additionally, because both the sympathetic and parasym-
pathetic ganglia utilize nicotinic cholinergic synapses, Abs that
interfere with ganglionic transmission may cause dysautono-
mia. AAG patients demonstrated widespread and severe auto-
nomic failure. Patients typically present with symptoms related
to sympathetic failure (e.g. orthostatic hypotension and anhi-
drosis), parasympathetic failure (e.g. impaired heart rate varia-
bility, dry mouth, and impaired pupil constriction), and GI
dysmotility.
In this review, we mentioned the extra-autonomic manifes-
tations as a sort of new entity. Baker et al. previously described
late-onset encephalopathy in AAG [38]. They found antibodies
that specifically bind neuronal α5 and α7 nAChRs. The α7
nAChR is a homopentameric ligand-gated ion channel predo-
minantly expressed in the cerebral cortex and hippocampus.
Gibbons et al. investigated the relationship between ortho-
static hypotension, antibody titers and cognitive impairment
in patients with AAG [39]. Recently, we reported a pediatric
AAG case presenting with acute encephalitis [91]. The nAChRs
comprise a family of abundantly expressed ligand-gated
cation channels found throughout the central and peripheral
nervous systems, especially in the hypothalamus. They are
involved in various neurobiological systems that have been
implicated in the pathophysiology of psychiatric symptoms.
nAChRs have roles in addition to that in cholinergic neuro-
transmission: they modulate dopamine function and hypotha-
lamic-pituitary-adrenal axis activity. Therefore, we speculated
that nAChRα3 and nAChRβ4 Abs may play a role in extra-
autonomic manifestations. Anti-gAChRα3 and anti-gAChRβ4
Abs, in addition to new Abs to other subunits of nAChRs in
the dorsal root ganglion and brain, have the potential to cause
extra-autonomic manifestations.
The seropositive AAG in our study had a significant over-
representation of autoimmune diseases. Autonomic dysfunc-
tions have been reported in association with Sjögren’s
syndrome [92,93], systemic sclerosis [94], systemic lupus erythe-
matosus [95], rheumatoid arthritis [96,97], and mixed connec-
tive-tissue disease [98]. Although AAG and other autoimmune
diseases can coexist due to the same background of autoimmu-
nity, few reports have referred to anti-gAChR Abs in these auto-
immune diseases [99–102]. We believe it is important to clarify
the clinical and immunological characteristics of the coexistence
of AAG and the other autoimmune rheumatic diseases.
In a clinical field of diagnosing AAG, sometime it is difficult to
differentiate AAG from other neuropathies with autonomic dys-
function such as AASN, GBS. Koike et al. reported testing for anti-
962 S. NAKANE ET AL.
gAChR Abs in 6 patients with AASN, all of whom were negative.
They demonstrated significant differences in the frequency of an
antecedent event, age and progression in comparison between
AASN and seropositive AAG [9]. We detected the anti-gAChR
Abs in approximately 10% in serum from patients with GBS
[103]. The levels of Abs in the seropositive GBS samples were
relatively low, which may be a bystander effect that reflects a
dysimmune state in GBS. Moreover, several research groups
have reported that patients with other neurological disorders
have Abs to gAChR and autonomic symptoms [100–102].
8. Five-year view
A better classification of AAG based on clinical features includ-
ing pediatric AAG and their clinical course, better autonomic
testing techniques with reliable biomarkers usable in routine
examination, advances in immunology and immunogenetics,
and increased knowledge in the medical professionals should
have an impact on the difficult of the approach in the clinical
diagnosis. Earlier clinical management and treatment invol-
ving precise inclusion criteria in clinical trials will probably
have an impact on the effectiveness of any immunotherapy.
We need to verify the pathogenicity of the gAChRα3 and β4
Abs, and it may be necessary to establish a new LIPS assay for
the detection of Abs to other subunits of nAChRs (e. g. α4, α5,
α7, β2 and etc.). An animal model of this disorder can be
induced in rabbits by immunization with ganglionic AChR sub-
unit proteins. Rabbits with experimental AAG (EAAG) manifest
symptoms of autonomic failure similar to those seen in AAG
patients and show a deficit in synaptic transmission in auto-
nomic ganglia. Furthermore, autonomic deficits can also be
transferred to mice by passive transfer of IgG from AAG patients
via serum [24,104]. The anti-gAChRα3 Abs could cause several
autonomic dysfunctions in an EAAG model [24,104,105].
However, it is unclear whether the anti-AChRβ4 Abs is involved
in the pathogenesis of AAG. Additional experiments and inves-
tigations using the animal model are necessary to clarify the role
of AChR β4 Abs in the pathogenesis of AAG involving the
autonomic and the extra-autonomic manifestations.
Key issues
● AAG is a rare disorder of antibody-mediated impairment of
transmission across the autonomic ganglia resulting in
severe autonomic failure, in which Abs to gAChR may play
a central role.
● LIPS was developed to diagnose AAG based on IgG antibo-
dies to both the α3 and β4 gAChR subunits in patient serum.
● A gradual mode of onset was more common in the patients
with AAG.
● AAG patients demonstrated widespread autonomic dys-
function, and orthostatic hypotension and GI dysmotility
were frequently observed.
● We found a significant overrepresentation of brain involve-
ment, sensory disturbance, autoimmune rheumatic disorders,
endocrinological disorders and as an extra-autonomic mani-
festaions of AAG in the seropositive AAG patients.
● 123I-MIBG myocardial scintigraphy may be a useful tool for
monitoring AAG.
● Further studies are required to clarify which immunother-
apy combination or which order of the immunotherapies
will be best for treating autonomic and extra-autonomic
manifestations of AAG.
● Immunotherapies, such as steroid pulse therapy, IVIg and plas-
mapheresis, are often effective and used as first-line treatment.
● Additional treatment with steroids, azathioprine, mycophe-
nolate mofetil, and rituximab, alone or in combination with
each other could be effective.
Acknowledgments
The authors are grateful to Drs Masataka Umeda, Kunihiro Ichinose, Hideki
Nakamura, Hitomi Minami, Hajime Isomoto, Akio Ido, Kiyoshi Migita, Kazuhiko
Nakao, and Atsushi Kawakami for useful discussions. The authors are indebted
to members of Kumamoto University Hospital Department of Neurology and
Nagasaki Kawatana Medical center Department of Neurology for discussing
some issues for this study and to Yuka Okumura, Keiko Hida, Haruna Akaishi,
and Haruka Ikezaki for providing excellent secretarial support.
Funding
This research was supported by AMED under Grant Number
18dk0310069h0003, and JSPS KAKENHI Grant Number 25461305 and
16K09695.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other
relationships to disclose.
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