Supplementary Table 1: Negative investigations in 17 patients with basal ganglia
encephalitis. All investigations on serum or plasma unless stated.
Biochemical
Number Autoimmune or infectious
Urine amino acids
17
Antinuclear antibody
15
Urine organic acids
17
Anti-ds DNA Ab
9
Urine Glycosaminoglycan
9
Extractable nuclear antigen antibody
5
Ammonia lactate
9
Anti-cardiolipin Ab
3
Copper + caeruloplasmin
9
ANCA
3
CSF Neurotransmitters
8
Anti-thyroid antibodies
2
Biotinidase
6
Coeliac antibodies
2
White cell enzymes
5
Very long chain fatty acids
5
CSF herpes simplex PCR
14
B12 folate
5
CSF enterovirus PCR
8
Transferin isoforms
4
CSF mycobacteria PCR
4
Thyroid function
4
CSF Varicella zoster PCR
3
Plasma amino acids
3
CSF Cytomegalovirus PCR
2
Carnitine
3
CSF Epstein Barr virus PCR
2
Urine toxicology
3
CSF fungal stain
2
Urine VMA
3
CSF JC virus PCR
1
Heavy metals
3
CSF measles IgG
1
ACE
2
Complement
2
Mycoplasma IgM
12
Urate
2
Epstein Barr virus IgM
12
Urine Porphyrins
2
Anti-Streptolysin-O titre
10
Malaria film
2
Varicella zoster IgM
6
Lipids
2
Human Immunodeficiency virus IgG
6
Alpha fetoprotein
2
Cytomegalovirus IgM
6
Herpes Simplex virus IgM
5
Toxoplasma IgM
5
Measles IgM
4
Lyme serology
3
Influenza IgG
3
Enterovirus IgM
3
Rubella IgM
3
Human Herpes virus 6 IgM
3
Hepatitis serology
2
Parvovirus,
serology,
mumps,
Q
fever,
Cat
stratch
1
Arbovirus,
Japanese B, Flavivirus, Coxiella,
Legionella, Chylamydia
Nasopharyngeal
aspirate
for
7
respiratory virus panel
Throat swab
IgG = immunoglobulin G
IgM = immunoglobulin M
6
Supplementary Table 2: Clinical details and demographics of controls (n = 67)
Control
Healthy Other
First episode of Viral
Anti-
Group
control
Neurological
demyelination
encephalitis NMDAR
(HC)
disorders (OND)
(DEM)
(V ENC) ‡
encephalitis
(NMDAR
ENC)
Number
18
22
8
11
8
Males
10
12
5
8
2
Mean,
11, 11
8.4, 8
9.25, 9.9
4.8, 3.2
6.5, 6.5
9-13
1-15
1.8-14.6
0.5-14
3-13
Healthy
Basal
Acute disseminated
Enterovirus
Positive
children
metabolic or genetic
encephalomyelitis
CSF pcr (n =
serum
(and
disease#,
or clinically isolated
6)
CSF)
anti-
syndrome*
Herpes
NMDAR
neurodegeneration,
Simplex CSF
antibodies¶
developmental
pcr (n = 4)
disorders
Varicella
median
age (yrs)
Age range
(yrs)
Details
ganglia
epilepsy,
stroke,
Zoster
CSF
pcr (n = 1)
#
Basal ganglia controls included Wilson’s disease, Leigh disease, Glutaric
aciduria type 1, basal ganglia stroke, Huntington disease
*
4/8 children with DEM were positive for anti-myelin oligodendrocyte
glycoprotein (MOG) antibodies (Brilot et al., 2009).
‡ Viral encephalitis confirmed aetiology using CSF PCR (Granerod et al., 2010).
¶ Clinical phenotype and investigation as described (Dale et al., 2009).
Supplementary Table 3: Ancillary tests, treatment, and outcome in 12 anti-D2R
antibody positive basal ganglia encephalitis children
Characteristic
Number
Brain MRI
Total abnormal
6/12
Putamen lesions (bilateral)
6/12
Caudate lesions (bilateral)
5/12
Globus Pallidus lesions (bilateral)
3/12
Midbrain, cerebral peduncle
3/12
Pons, frontal cortex, thalamus
1/10 each
Cerebrospinal fluid
Total with abnormal findings
9/12
Lymphocyte pleocytosis (>5 cells/mm3)*
3/12
Protein (>0.4 mg/dl)
6/12
Intrathecal oligoclonal bands
4/10
Mirrored oligoclonal bands
3/10
Electroencephalography
Normal
5/10
Slowing
5/10
Epileptic activity
0/10
Treatment
IVMP, then oral prednisolone ‡
5/12
IVMP, then oral prednisolone, IVIG¶ ♯
2/12
Nil
5/12
Outcome
Length of follow-up, mean, median (range) years
5.3, 5.25 (1-10)
Full recovery
5/12
Dystonia
3/12
Motor tics
1/12
Cognitive disorder
5/12
ADD†
4/12
Psychosis
2/12
OCD, ODD, ASD, anxiety§
1/12 each
* CSF Lymphocyte range 0-30 cells/mm3, median 1 cell/mm3
‡ IVMP= Intravenous methyl-prednisolone
¶IVIG= Intravenous immunoglobulin
♯ = complete treatment: 30mg/kg/day of Methylprednisolone for three days
followed by three months of tapered oral prednisolone (starting 2mg/kg/day for
one
month).
In
addition,
patients
were
given
2g/kg of
intravenous
immunoglobulin at the same time as the intravenous steroid.
†ADD = Attention deficit disorder
§OCD = Obsessive compulsive disorder, ODD= Oppositional defiant disorder,
ASD = autistic spectrum disorder
Supplementary Table 4: Clinical features, acute Magnetic resonance imaging
features and outcome of basal ganglia encephalitis patients with anti-D2R
antibodies
Age Movement Psychiatric
sex
disorder
Other
MRI
and
Outcome
lesions
cognitive
symptoms
1.6
Chorea
Agitation
F
Insomnia
Normal
Hypotonia
Loss
Relapse (2mth)
Normal (1.5 yr) **
of
ambulation
3.5
Chorea
Personality
Ataxia
F
Ocular flutter
change
tremor
Normal
Relapse (3m, 12m)
Normal (2 yr) **
cognitive
decline
3.5
Parkinsonism
M
Dystonia
Agitation
Lethargy
Caudate
Coordination disorder
Slurred speech
Putamen
Anxiety
Encephalopathy
Cognitive
disorder,
mild (8 yr)
4M
Dystonia
-
Dystonic
Encephalopathy
Caudate,
Seizure
putamen,
tremor
5F
Normal (1 yr) *
frontal cortex
Parkinsonism
Emotional
Insomnia
Normal
ADD
Dystonia
lability
Confusion
ODD
Pyramidal
Rigid behaviours
weakness
Hemidystonia (5 yr) *
5M
6F
Parkinsonism
Parkinsonism
-
-
Somnolence
Putamen
Normal (10 yr)
Ophthalmoplegia
Thalamus
Pyramidal
Midbrain
weakness
Pons
Lethargy
Caudate
Motor tics
Ataxia
Putamen
ADD
Cerebellar signs
Globus
Rigid thinking (4 yr)
Pallidus
7F
Chorea
Aggression
Encephalopathy
Caudate
Inattentive ADD
Seizure
Putamen
Impulsive
Globus
Anxiety
Pallidus
Cognitive
Cerebral
mild (8 yr) *
disorder,
peduncle
9F
Hemi-
Hallucinations
Ophthalmoplegia
Caudate
Relapse (8 yr)
dystonia
Disinhibition
Mutism
Putamen
Dystonia
Hemi-chorea
Compulsive
Hiccough
Globus
ADD
OGC
touching
Pallidus
Autistic
Cerebral
disorder
peduncle
OCD
spectrum
Bipolar disorder
Cognitive deficit (9
yr) *
14
Dystonia
Agitation
M
Encephalopathy
Normal
Dystonia
Cardiac
Cognitive
arrhythmia
mild
disorder,
(5.5 yr) *
15
Dystonia
Psychosis
Mutism
M
(orofacial)
Paranoia
Poor eye contact
Normal
Psychosis (9yr) *
OGC
Agitation
Compulsive
touching
15
Parkinsonism
Psychosis
Somnolence
M
OGC
Paranoia
Hiccough
Anxiety,
Pupillary
agitation
dilatation
Normal
Normal (2 yr)
*Patients receiving intraveneous Methyl prednisolone then oral prednisolone for 4 or
more weeks in acute phase.
**Patients receiving intravenous Methyl prednisolone and oral prednisolone for 4 or
more weeks, and IVIG
ADD = Attention deficit disorder, ODD = oppositional defiant disorder, OCD =
obsessive-compulsive disorder, OGC = oculogyric crises
Supplementary Table 5: Clinical comparison of anti-D2R antibody-positive (n =
10) and –negative Sydenham chorea patients (n = 20)
Characteristic
Anti-D2R
Anti-D2R
antibody-
antibody-
positive (n = negative (n =
10)
20)
Female sex
9/10
15/20
Age mean (range)
8.4 (2-13)
11.9 (7-16)
Non-white
5/10
6/20
Infection
7/10
12/20
Positive ASOT >200 IU/ml
10/10
18/20
Chorea
8/10
14/20
Hemichorea
2/10
6/20
Any psychiatric symptoms
7/10
16/20
Emotional lability, anxiety
7/10
14/20
Personality change
6/10
14/20
Attention deficit hyperactivity disorder
2/10
4/20
Demographics
Prodromal symptoms
Movement disorder
Psychiatric symptoms
Generalised anxiety disorder
0/10
5/20
Dysarthria
6/10
13/20
Carditis
6/10
13/20
Arthritis or arthralgia
5/10
8/20
Fever
1/10
4/20
Other
ASOT = anti-Streptococcal-O titre
Supplementary figure legends:
Supplementary Fig. 1: Basal ganglia encephalitis is not associated with anti-D3R,
anti-D1R, and anti-DAT antibody. Anti-human surface D3R (A), D1R (B) and DAT
(C) IgG antibody were detected using flow cytometry cell-based assays. Patients with
Basal ganglia encephalitis do not have anti-D3R, anti-D1R, or anti-DAT antibody.
15/17 (D3R and D1R) and 14/17 (DAT) basal ganglia encephalitis sera were available
for testing. Representative dot plots out of three experiments are shown.
Supplementary Fig. 2: Anti-D2R antibody-positive encephalitis sera do not bind
hemagglutinin. Because the extracellular N-terminus of D2R cDNA is tagged with the
human influenza hemagglutinin (HA) tag, we controlled that anti-D2R IgG antibody
detected in basal ganglia encephalitis (BG ENC) did not bind to the hemagglutinin tag
using hemagglutinin-D5R and hemagglutinin-syntaxin 4. Extracellular N-terminal
hemagglutinin-D5R (A) and extracellular C-terminal hemagglutinin-syntaxin 4 was
expressed at the surface HEK293 cells (C), and we performed cell-based assays.
Threshold was defined as mean of healthy control + 3SD (dotted line on graph). (B)
Anti-surface human hemagglutinin-D5R antibody were detected in 0/67 controls and
0/17 basal ganglia encephalitis (BG ENC) sera. (D) Anti-surface rat hemagglutinin
syntaxin-4 IgG antibody was detected in 0/13 healthy control (HC), 0/8 anti-NMethyl D-Aspartate Receptor encephalitis (NMDAR ENC), and 0/17 basal ganglia
encephalitis sera. Representative dot plots out of three experiments are shown. (E)
Representative flow cytometry histograms are shown for an anti-D2R antibody
positive basal ganglia encephalitis serum. MFI values are noted in legend.
Supplementary Fig. 3: Acute (A) and convalescent (C) anti-D2R antibody in three
basal ganglia encephalitis patients. Patients A and B were diagnosed retrospectively
with anti-D2R antibody-positive encephalitis, whereas patient C was diagnosed
prospectively. Patient A, a 5 year old female presented with encephalitis, dystoniaparkinsonism, and confusion. Her MRI was normal and she was treated with oral
prednisolone 2mg/kg for 2 weeks then a 6 week taper. The patient was reported to
have made little improvement at annual reviews, and at 5 year follow-up she has
residual hemidystonia, attention deficit disorder, rigid behaviours, and her anti-D2R
antibodies remain elevated. Patient B, a 3 year old male presented with encephalitis,
encephalopathy, dystonia-parkinsonism, and agitation. His MRI showed caudate and
putamen lesions. He was treated with intravenous methylprednisolone 30mg/kg for 3
days then oral prednisolone 2mg/kg for 2 weeks, then an 8 week steroid taper. The
patient was reported to have made little improvement at annual reviews, and at 8 year
follow-up he has residual coordination disorder, anxiety, and mild learning
difficulties, and his anti-D2R antibodies remain elevated. Patient C, a 3 year old
female presented with encephalitis with chorea, ataxia, ocular flutter, developmental
regression, and two relapses in the first 12 months. Her MRI was normal. She was
given 2g/kg of intravenous immunoglobulin monthly for three months. She was also
given oral prednisolone 2mg/kg/day for one month and remains on 1mg/kg
prednisolone on alternate days. One year after starting treatment, her chorea and
ataxia have resolved, she has made significant developmental gains, and her
development is now normal. Her anti-D2R antibody is now within the healthy control
range (below threshold of positivity). Dotted lines on graphs represent the positivity
threshold (obtained with 24 HC samples). P: prednisolone; IVIG: intravenous
immunoglobulin. Representative dot plot out of three experiments is shown.
Supplementary Material:
Brief case histories of anti-D2R antibody-positive Tourette syndrome patients
Case 1: A male Caucasian patient whose father had Tourette syndrome and attention
deficit hyperactivity disorder presented with his tic disorder at 5 years of age. At the
time of serum testing (15 years), he had severe Tourette syndrome plus comorbid
attention deficit hyperactivity disorder, oppositional defiant disorder, obsessive
compulsive disorder, generalised anxiety disorder and depression, and was severely
impaired despite multiple medication trials. His anti-Streptolysin-O titre (ASOT) at
time of serum testing was elevated at 400 IU/ml, but there was never any infectionassociated exacerbations during his disease course.
Case 2: A male Asian patient with no family history of note presented at 6 years of
age with tic disorder. At the time of serum testing (7 years of age) he had motor and
vocal tics for more than 12 months, but had no associated comorbidity. His course
waxed and waned but his impairment did not require medical treatment. His ASOT
was negative at 50 IU/ml, and there has never been any infection-associated
exacerbations during his disease course.
Case 3: A female Caucasian patient whose mother has longstanding throat clearing
presented at 7 years of age with tic disorder. The patient has had motor and vocal tics
for 8 years, and her course has relapsed and remitted in a more exaggerated way than
typical Tourette syndrome, but there has never been a deterioration associated with
infection. At the time of serum testing (15 years old), she still has Tourette syndrome,
but no associated comorbidity. Her ASOT at the time of serum testing was negative at
55 IU/ml.
Case 4: A female Caucasian patient whose sister has alopecia and father has
obsessive-compulsive disorder presented at 4 years of age with tic disorder. At the
time of serum testing (8 years), she had Tourette syndrome, generalised anxiety
disorder, separation anxiety, and obsessive compulsive behaviour. She has had a
predisposition to Streptococcal infections, but there have not been any clear infectionassociated exacerbations. Her ASOT at the time of serum testing was elevated at 455
IU/ml.