Evaluation of the Cunningham Panel™ in PANDAS and PANS: Changes in antineuronal antibody titers parallel changes in patient symptoms

Published: Journal of Neuroimmunology

Watch Video: Evaluation of the Cunningham Panel™

Dr. Craig Shimasaki, CEO and President, Moleculera Labs, reviews findings from the study, which describes the sensitivity, specificity and accuracy of the Cunningham Panel™ for patients with PANS and PANDAS.

This is Craig Shimasaki. I'm CEO and President of Moleculera Labs and I would like to share with you a newly published study entitled "Evaluation of the Cunningham Panel in Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (otherwise known as PANDAS) and Pediatric Acute-Onset Neuropsychiatric Syndrome” (otherwise known as PANS).

Changes in anti-neuronal antibody titers parallel changes in patients symptoms. So by way of background, I just wanted to share with you briefly about the targets of the anti-neuronal antibodies in the Cunningham Panel.

There are 5 tests and these 5 tests measure for autoantibody titers and a self-stimulatory activity. As you can see here, the majority of them are directed against pre- and post-synaptic neurons, in particular the Dopamine D1 and D2 receptors and the Lysoganglioside and Tubulin, which is an intracellular protein. The 5th assay is a cell stimulatory assay and that particular assay measures the activation of the Calmodulin CaMKinase 2 and that's important because it upregulates the synthesis of Dopamine, Epinephrine and Norepinephrine in the cell.

As you can see here this represents the test results and as you can see the 5 different tests Dopamine D1, D2, Lysoganglioside, Tubulin and Calmodulin CaMKinase, along with the antibody and the activity scores.

The retrospective case study, in which we examine the correlation of these anti-neural antibody changes in patients who had a test one before and after treatment and had clinical documentation of treatment and also their symptoms before and after treatment.

So we examined all the results that we had. There were approximately 2,000 patients who had been tested and we identified 206 patients who fell within that period of time and had 2 or more tests pre- and post-treatment.

We ended up with 58 patients that did provide a written consent who were not in a study already. And patients who we were able to contact and able to retrieve medical records, clinical data and symptoms and treatment.

We then categorized those 2 patient populations into Group 1 and Group 2. Group 1 were those patients who completely resolved their symptoms or they greatly improved. Group 2 were the patients who did not improve and many of them had their symptoms worsened.

So that included 58 patients. All were then analyzed.

You can see the clusters of symptoms by frequency and percent of patients in Group 1and Group 2. All patients met the criteria for PANDAS or PANS, including a sudden onset of symptoms. We examined within Group 1 and Group 2.

Group 1 - again these were patients who did completely improve or resolve or improve significantly. Group 2 - those patients who did not improve or actually worsened. You can see the age range was similar. The mean age in years was approximately 12 years. The ratio of female to male was identical and the mean time between the 1rst and 2nd Cunningham Panel test was approximately 66 and 68 weeks. There were no statistical difference between the groups in the age or gender distribution. And there was no statistical difference between Group 1 or Group 2 in the time between tests.

We looked at a heat map of the patients in Group 1. Looking at their pre-treatment results, you can see that all patients within Group 1 had at least 1 or more positive tests in the Cunningham Panel. The intensity of the red indicates the degree of elevation of these autoantibody assays. And in post-treatment, we found in Group 1 (patients who improved or resolved) was there was this dramatic difference in their treatment or their results post- treatment. As you can see, the majority of them resolved to baseline and if they didn't resolve to baseline, many had reduced the number of tests positive or the intensity. When looking at just the number of positive tests per patient you can see in blue pre-treatment, significant difference in those patients the number of positive tests post treatment.

When we looked at patients in Group 2 (those that did not improve or their symptoms actually worsened) what we identified is that indeed those patients pretreatment did have positive tests. However, there was a group that did not have positive tests but met the criteria for symptoms for PANDAS and PANS.

However on post-treatment results we also see that not only many of them had a positive test which we believe is a characteristic of the time lag in which these antibodies are generated but we also see the significant difference or the increase in the number of positive tests in these patients and when you look at that graphically what you can see is patients pre-treatment in blue the number of positive tests post-treatment in orange.

So when you're looking at that graphically in patients in Group 1 looking at those that had a number of positive tests, 18 having a positive D1, 6 had positive D2R, 20 had a positive anti-tubulin, 6 for lysoganglioside. 27 for CaMKinase, whereas post-testing only 2 to 5, 0 and 8 respectively, contrast that to patients in Group 2 who showed no improvement or actually worsened. What you can see in these tests is the patient test actually had either more positives or equivalent positives.

We then looked at the sensitivity and specificity of the Cunningham Panel results as far as symptoms correlating to positive test results, what we found was a sensitivity of 88%, specificity of 83% and an overall accuracy of 86%.

Graphically looking at these in dot blots you can see that there is good separation between patients in Group 1 and Group 2 and when plotted on a receiver operator characteristic curve (ROC curve) you can see the area under the curve is 93.4%.

We looked at the data in another way irrespective of what was a positive or negative. We looked at the degree or the magnitude of change in the results and through a logistic regression we took all 5 tests and assigned them a score and identified and measured them in electric logistic regression analysis.

In doing so, we found a very similar sensitivity and specificity 88% and 92% with an overall accuracy of 90% but when you look at the separation between the two groups you can see much clearer separation and this provides future value and the idea of the possibility of 5 different tests each contributing to the results but no one individual tests by itself can contribute the benefit of all the results.

Again, when you look at the ROC curve, you can see that as a similar area under the curve of 95.7%. When we look at the CaMKinase activity alone and compare that to Group 1 vs. Group 2, what we find is that the mean score for CaMKinase is significantly and statistically different.

Patients who in Group 1 (who improved are completely resolved) as you can see had an average about a 150 CaMKinase activity. Positive is a threshold of 130. And you can see that pre- and post- for group 2, there is no statistical difference between those patients.

What this leads us to is some conclusions that patients may have differing underlying etiology for various types of clinical symptoms. For tics, OCD, eating disorders, anxiety. Whereas we know that PANDAS and PANS is a clinical diagnosis but it also includes many of those symptoms and it's quite possible that various symptoms like tics, OCD, eating disorders and anxiety - portions of them - can actually have an underlying autoimmune ideology which we actually see with the results in the Cunningham Panel.

This leads us to the potential conclusion and has been identified in many other publications –that clinical diagnosis of disorders such as epilepsy, schizophrenia, ASD, ADD and ADHD, chronic depressive disorder, which are clinically diagnosed - a portion of each of those may have an underlying autoimmune etiology.

The benefit to this is that precision medicine would allow the differentiation of patients to be treated based upon the underlying etiology rather than be treated by the symptoms.

And in fact, that is what we see in practical studies – that patients when identified and separated by the underlying etiology respond better and more effectively to treatments that are directed against the underlying root cause.

This is the basis of precision medicine in cancer therapy and we believe that this is where autoimmune or underlying neuropsychiatric disorders will be headed, in which we can identify patients based upon an underlying etiology, treat the underlying etiology vs. treating the symptoms.

Read Translational Psychiatry Article
Read Published Frontier Psychiatry Article
Read Brain, Behavior and Immunity Article
Read Case Reports in Psychiatry
Read Physician Testimonials about the Cunningham Panel
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B. Robert Mozayeni, MD

Medical and Clinical Advisor

B. Robert Mozayeni MD

Dr. B. Robert Mozayeni was trained in Internal Medicine and Rheumatology at Yale and at NIH. He has had pre- and post-doctoral Fellowships in Molecular Biophysics and Biochemistry at Yale, and also at NIH where he was a Howard Hughes Research Scholar at LMB/DCBD/NCI and later, Senior Staff Fellow at LMMB/NHLBI/NIH. Editorial board of Infectious Diseases – Surveillance, Prevention and Treatment. Past President of the International Lyme and Associated Diseases Society (ILADS).

He is an expert in Translational Medicine, the science and art of advancing medical science safely and efficiently. He is a Fellow of the non-profit Think Lead Innovate Foundation and is a co-founder of the Foundation for the Study of Inflammatory Diseases. He is a Founder of the Foundation for the Study of Inflammatory Diseases to crowd-source medical solutions for complex conditions using existing knowledge, diagnostic methods, and therapies to meet patient needs immediately. He is the Chief Medical Officer of Galaxy Diagnostics, LLC. He is a Board member of the Human-Kind Alliance. Dr. Mozayeni has held admitting privileges (since 1994) on the clinical staff of Suburban Hospital, a member of Johns Hopkins Medicine and an affiliate of the National Institutes of Health Clinical Center.

Safedin Sajo Beqaj, PhD, HCLD, CC (ABB)

Moleculera Labs, Clinical Laboratory Advisor
Medical Database, Inc., President and CEO

Sajo Baqaj, PhD

Dr. Sajo Beqaj is board certified in molecular pathology and genetics and licensed as a Bioanalyst and High Complexity Laboratory Director. He has been practicing as a laboratory director since 2005.

Dr. Beqaj served as a technical director and was part of the initial management team for several well-known laboratories in the clinical lab industry including PathGroup, Nashville, TN; DCL Medical Laboratories, Indianapolis, IN, and Pathology, Inc, Torrance, CA. He is currently serving as off-side CLIA laboratory director for BioCorp Clinical Laboratory, Whittier, CA and Health360 Labs, Garden Grove, CA.

Dr. Beqaj received his Ph.D. in Pathology from Wayne State University Medical School, Detroit, Michigan. He performed his post-doctoral fellowship at Abbott Laboratories from 2001-2003 and with Children’s Hospital and Northwestern University from 2003-2005.

Dr. Beqaj has taught in several academic institutions and has published numerous medical textbook chapters and journal articles. He has served as a principal investigator in clinical trials for several well-known pharmaceutical and diagnostic companies such as Roche HPV Athena, Merck HPV vaccine, BD vaginitis panel, Roche (Vantana) CINtec® Histology clinical trials, and has presented various scientific clinical abstracts and presentations.

He is a member of several medical and scientific associations including the Association of Molecular Pathology, American Association of Clinical Chemistry and the Pan Am Society for Clinical Virology. He has served on a number of clinical laboratory regulatory and scientific committees, and has assisted several laboratories and physicians as a Clinical Laboratory Consultant.