[16]. In the present study we focused on the establishment of serologic antibody testing methods since the availability of CSF was limited, the collection of CSF is invasive, and serum testing often produces more background than CSF testing. A study investigating the largest known cohort of NMDAR encephalitis patients [4] found a better correlation of CSF antibody titer with get Vorapaxar disease activity, and CSF was suggested to be more sensitive than serum [29]. Future investigations should aim to optimize the FACS based analysis to provide more reliable results, even when only low CSF volumes are available. Controversial data exist regarding NMDAR antibody levels in serum and their clinical relevance [30], further underlined by a recent study using a live CBA with fixation after serum incubation that showed serum positivity in 23 of patients with an unlikely autoimmune syndrome, as well as CSF negativity in some cases considered with definite NMDAR encephalitis [31]. In contrast to their live CBA, here we used endpoint titration instead of a visual scoring system. Furthermore, we found that protection of the NMDAR overexpressing cells is necessary throughout the assay to assure their survival, which is of particular importance when assessing undiluted CSF. One limitation of our assay is that we used only sera of NMDARPLOS ONE | DOI:10.1371/journal.pone.0122037 March 27,14 /A Live Cell Based Assay for Detection of NMDAR Antibodiesencephalitis patients that had a definite clinical diagnosis partly based on their seropositivity to assess specificity and sensitivity. This limitation is in part caused by the fact that using previously established criteria that confer high specificity and sensitivity [16], some of the authors (RH and JD) never encountered patients with NMDAR encephalitis without antibodies in the CSF, or patients with serum NMDAR antibodies and an unlikely autoimmune disorder. It is therefore even more important to launch a multicenter study to compare results of different laboratories that conduct NMDAR antibody testing. In conclusion, we compared two highly sensitive serologic testing methods to detect autoantibodies to NMDAR. In our experience both methods had a high specificity, whereas the sensitivity of the immunofluorescence CBA was higher than that of the FACS assay. This might be especially important for the analysis of CSF antibodies, since they are crucial for the diagnosis of NMDAR encephalitis, and a particularly high sensitivity is needed due to the low amounts of immunoglobulins that can be present in CSF.Supporting InformationS1 Fig. Staining of NMDAR overexpressing HEK293A cells with antibodies against NMDAR subunits. Cells stained with antibodies against NR1 (A), NR2A (B), and NR2B (C) are shown, respectively.(Em)GFP = (emerald) green fluorescent EPZ-5676 solubility protein. NMDAR = N-methylD-aspartate receptor. (TIF) S2 Fig. Survival and transfection rates of NMDAR-(Em)GFP overexpressing HEK293A cells 48 h post transfection. Dead cells are 7-AADpos, NMDAR expressing cells EmGFP/ GFPpos. Means of two experiments are shown, bars indicate standard deviation.7-AAD = 7-amino-actinomycin D. (Em)GFP = (emerald) green fluorescent protein. NMDAR = N-methylD-aspartate receptor. (TIF) S3 Fig. MFI and MFI obtained by FACS analysis in NMDAR-IgG positive samples as determined by CBA. CBA+FACS+ show samples where NMDAR antibodies were detected with both methods, CBA+FACS- represent samples that were positive in the CBA, but (false) negative in the F.[16]. In the present study we focused on the establishment of serologic antibody testing methods since the availability of CSF was limited, the collection of CSF is invasive, and serum testing often produces more background than CSF testing. A study investigating the largest known cohort of NMDAR encephalitis patients [4] found a better correlation of CSF antibody titer with disease activity, and CSF was suggested to be more sensitive than serum [29]. Future investigations should aim to optimize the FACS based analysis to provide more reliable results, even when only low CSF volumes are available. Controversial data exist regarding NMDAR antibody levels in serum and their clinical relevance [30], further underlined by a recent study using a live CBA with fixation after serum incubation that showed serum positivity in 23 of patients with an unlikely autoimmune syndrome, as well as CSF negativity in some cases considered with definite NMDAR encephalitis [31]. In contrast to their live CBA, here we used endpoint titration instead of a visual scoring system. Furthermore, we found that protection of the NMDAR overexpressing cells is necessary throughout the assay to assure their survival, which is of particular importance when assessing undiluted CSF. One limitation of our assay is that we used only sera of NMDARPLOS ONE | DOI:10.1371/journal.pone.0122037 March 27,14 /A Live Cell Based Assay for Detection of NMDAR Antibodiesencephalitis patients that had a definite clinical diagnosis partly based on their seropositivity to assess specificity and sensitivity. This limitation is in part caused by the fact that using previously established criteria that confer high specificity and sensitivity [16], some of the authors (RH and JD) never encountered patients with NMDAR encephalitis without antibodies in the CSF, or patients with serum NMDAR antibodies and an unlikely autoimmune disorder. It is therefore even more important to launch a multicenter study to compare results of different laboratories that conduct NMDAR antibody testing. In conclusion, we compared two highly sensitive serologic testing methods to detect autoantibodies to NMDAR. In our experience both methods had a high specificity, whereas the sensitivity of the immunofluorescence CBA was higher than that of the FACS assay. This might be especially important for the analysis of CSF antibodies, since they are crucial for the diagnosis of NMDAR encephalitis, and a particularly high sensitivity is needed due to the low amounts of immunoglobulins that can be present in CSF.Supporting InformationS1 Fig. Staining of NMDAR overexpressing HEK293A cells with antibodies against NMDAR subunits. Cells stained with antibodies against NR1 (A), NR2A (B), and NR2B (C) are shown, respectively.(Em)GFP = (emerald) green fluorescent protein. NMDAR = N-methylD-aspartate receptor. (TIF) S2 Fig. Survival and transfection rates of NMDAR-(Em)GFP overexpressing HEK293A cells 48 h post transfection. Dead cells are 7-AADpos, NMDAR expressing cells EmGFP/ GFPpos. Means of two experiments are shown, bars indicate standard deviation.7-AAD = 7-amino-actinomycin D. (Em)GFP = (emerald) green fluorescent protein. NMDAR = N-methylD-aspartate receptor. (TIF) S3 Fig. MFI and MFI obtained by FACS analysis in NMDAR-IgG positive samples as determined by CBA. CBA+FACS+ show samples where NMDAR antibodies were detected with both methods, CBA+FACS- represent samples that were positive in the CBA, but (false) negative in the F.
