Influential factors and predictors of anti-N-methyl-D-aspartate receptor encephalitis associated with severity at admission

The clinical value of the neutrophil-to-lymphocyte ratio, systemic immune-inflammation index, monocyte-to-lymphocyte ratio and platelet-to-lymphocyte ratio for predicting the severity of patients with autoimmune encephalitis

Background

The systemic inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and platelet-to-lymphocyte ratio (PLR) are inflammatory markers in peripheral blood, which have been proven to be associated with some central nervous system diseases. We aimed to evaluate the association of SII, NLR MLR and PLR with the severity of autoimmune encephalitis (AE) and to compare the predictive value of those biomarkers in the early identification of ICU admission.

Methods

This retrospective study was conducted in three medical centers in China. We included 176 patients diagnosed with AE and 200 age and gender-matched healthy controls and correlated their demographic and clinical data. The SII, NLR, MLR and PLR levels were calculated from the blood routine tests. The severity of the patients was evaluated by the Clinical Assessment Scale for Autoimmune Encephalitis (CASE) and the modified Rankin Scale (mRS) at admission, and the patients were divided into two groups according to the ICU admission.

Results

The SII, NLR, MLR and PLR were significantly higher in AE patients than that in HCs (<0.001 for all). The SII and NLR were positively correlated with the CASE score (r = 0.243, p = 0.001; r = 0.237, p = 0.002) and the mRS score (r = 0.185, p = 0.014; r = 0.185, p = 0.014) in AE patients. The MLR and PLR were only positively correlated with the CASE score (r = 0.242, p = 0.001; r = 0.158, p = 0.036). The SII and NLR of the ICU group were significantly higher than that of the non-ICU group. The result of receiver operating characteristic (ROC) analysis showed that NLR was the best predictor of ICU admission for AE patients (AUC = 0.701). NLR and MLR had similar predictive ability (AUC = 0.654; AUC = 0.608) and were superior to PLR. The optimal NLR cut-off value for the incidence of ICU was 3.906.

Conclusion

Increased SII, NLR, MLR and PLR at admission are positively correlated with the CASE score of AE patients. Among the four indexes, the NLR is the best predictor of ICU admission, which may be helpful for clinicians to monitor disease progression and identify potentially severe patients of AE.

The Percentage of Neutrophils is Independently Associated with Blood-Brain Barrier(BBB) Disruption in Myelin Oligodendrocyte Glycoprotein Antibody Associated Disease (MOGAD)

Purpose

This study aims to investigate the risk factors associated with blood-brain barrier(BBB) disruption in patients with myelin oligodendrocyte glycoprotein antibody associated disease(MOGAD).

Patients and Methods

We collected clinical data from 95 patients diagnosed with MOGAD at the Department of Neurology, the First Affiliated Hospital of Zhengzhou University from October 2018 to May 2024. Patients were classified into normal or damaged BBB groups based on cerebrospinal fluid (CSF) albumin/serum albumin (QAlb). Binary logistic regression analysis was used to evaluate the risk factors for BBB disruption in MOGAD patients.

Results

Our study revealed that in MOGAD patients with BBB damaged, there is a higher proportion of acute phase high EDSS scores, higher incidence of prodromal symptoms, and a higher rate of viral infections. Myelitis is the main clinical phenotype, with clinical manifestations primarily including limb weakness and bladder/bowel dysfunction. Laboratory tests showed higher levels of CSF protein, immunoglobulin (IgG), 24-hour intrathecal IgG synthesis rate, peripheral blood leukocytes, neutrophil percentage, NLR, anti-thyroglobulin antibodies(TGAbs), and fibrinogen levels, while free triiodothyronine (FT3) and lymphocyte percentage were lower. Multivariate regression analysis indicated that an increased neutrophil percentage is an independent risk factor for BBB damage in MOGAD patients (OR=1.068, 95% CI: 1.018-1.122, P=0.008).

Conclusion

Neutrophil percentage is a readily available and widely used indicator reflecting the immune system's state and the body's inflammation level. The change in neutrophil percentage is independently associated with BBB damage in MOGAD patients. This finding helps provide more reference information for personalized treatment decisions and further research into the pathogenesis of MOGAD.

Validation of the clinical assessment scale for autoimmune encephalitis in a severe autoimmune encephalitis cohort

Objective

The Clinical Assessment Scale for Autoimmune Encephalitis (CASE) is a novel tool tailored specifically for evaluating the severity of autoimmune encephalitis (AE). However, its application in severe AE patients is limited. This study aimed to evaluate the reliability and validity of the CASE and explore its clinical significance in a severe AE cohort.

Methods

The relevant clinical characteristics, laboratory data, and prognosis of patients diagnosed with severe AE between April 2017 and April 2023 were collected. The CASE and modified Rankin scale (mRS) were performed at admission, discharge, and 1-year follow-up, respectively. The reliability of CASE was validated by calculating the Cronbach's alpha value. The validity was evaluated by calculating the Spearman's rank correlation with the corresponding mRS. Univariate and multivariate logistic regression were utilized to identify risk factors for poor prognosis.

Results

A total of 140 patients were recruited for the study. The CASE scale presented great internal consistency, with Cronbach's α value of 0.768 for the total score. The Spearman's rank correlation analysis revealed strong criterion validity between CASE and mRS, with coefficients of 0.68, 0.92, and 0.95 at admission, discharge, and 1-year follow-up, respectively (all p < 0.001). ROC analysis identified CASE score at admission served as a promising predictive marker for clinical response to treatment, with an AUC of 0.67 (95% CI: 0.57-0.77, p = 0.003). The optimal cut-off point was 22.5. At 1-year follow-up, 72/140 (51.4%) patients achieved good functional status (mRS, 0-2). Multivariate logistic regression confirmed that higher CASE scores on admission and older age at onset were associated with poor short-term as well as 1-year prognosis, respectively. In addition, no clinical response to treatment (OR = 40.499; 95% CI: 7.077-231.746, p < 0.001) and longer duration of hospitalization (OR = 1.071; 95% CI: 1.017-1.128, p = 0.010) were associated with poor function states at 1-year follow-up.

Conclusion

The CASE has proven suitable for evaluating disease severity and prognosis in severe AE patients. Besides, CASE score, age at disease onset, hospital stays, and response to immunotherapy are identified as independent risk factors for unsatisfactory prognosis in severe AE patients.

Clinical characteristics and outcomes of patients with antibody-related autoimmune encephalitis presenting with disorders of consciousness: A prospective cohort study

OBJECTIVE

To explore the clinical characteristics, short- and long-term functional outcomes, and risk factors for antibody-related autoimmune encephalitis (AE) in patients with disorders of consciousness (DoC).

METHODS

Clinical data were collected from AE patients admitted to Xuanwu Hospital of Capital Medical University from January 2012 to December 2021, and patients were followed up for up to 24 months after immunotherapy.

RESULTS

A total of 312 patients with AE were included: 197 (63.1%) with anti-NMDAR encephalitis, 71 (22.8%) with anti-LGI1 encephalitis, 20 (6.4%) with anti-GABAbR encephalitis, 10 (3.2%) with anti-CASPR2 encephalitis, 10 (3.2%) with anti-GAD65 encephalitis, and 4 (1.3%) with anti-AMPAR2 encephalitis. Among these patients, 32.4% (101/312) presented with DoC, and the median (interquartile range, IQR) time to DoC was 16 (7.5, 32) days. DoC patients had higher rates of various clinical features of AE (p < .05). DoC was associated with elevated lumbar puncture cerebrospinal fluid (CSF) pressure, CSF leukocyte count, and specific antibody titer (p < .05). A high percentage of patients in the DoC group had a poor prognosis at discharge and at 6 months after immunotherapy (p < .001), but no significant difference in prognosis was noted between the DoC group and the non-DoC group at 12 and 24 months after immunotherapy. Dyskinesia (OR = 3.266, 95% CI: 1.550-6.925, p = .002), autonomic dysfunction (OR = 5.871, 95% CI: 2.574-14.096, and p < .001), increased CSF pressure (OR = 1.007, 95% CI: 1.001-1.014, p = .046), and modified Rankin scale (mRS) score ≥3 at the initiation of immunotherapy (OR = 7.457, 95% CI: 3.225-18.839, p < .001) were independent risk factors for DoC in AE patients.

CONCLUSION

DoC is a relatively common clinical symptom in patients with AE, especially critically ill patients. Despite requiring longer hospitalization, DoC mostly improves with treatment of the primary disease and has a good long-term prognosis after aggressive life support and combination immunotherapy.

Blood and CSF findings of cellular immunity in anti-NMDAR encephalitis

OBJECTIVES

To investigate the immunopathogenic mechanisms of anti-N-methyl-D-aspartate receptor encephalitis (NMDAR-E) by characterizing the changes of immune cells in both peripheral blood (PB) and cerebrospinal fluid (CSF) of patients with NMDAR-E.

METHODS

Cytology and flow cytometry were used to explore and compare different immunological parameters in PB and CSF of patients with NMDAR-E, viral encephalitis (VE) and healthy volunteers. Moreover, different models were established to assess the possibility of identifying NMDAR-E patients based on PB and CSF parameters.

RESULTS

The neutrophil counts and monocyte-to-lymphocyte ratios (MLR) in PB are higher in NMDAR-E patients than in both VEs and controls (P < 0.001, respectively), while the percentages of CD3 + T, CD4 + T lymphocytes, and the leukocytes count in CSF were lower in NMDAR-Es than in VEs (P < 0.01, respectively). The higher percentages of CD8 + T cells in blood and CSF were both correlated with more severe NMDAR-E (P < 0.05, respectively). The poor neurological status group had significantly higher PB leukocytes but lower CSF leukocyte count (P < 0.05). Longitudinal observations in patients with NMDAR-E showed a decreasing trend of leukocyte count, neutrophils count, neutrophil-to-monocyte ratios (NMR), and neutrophil-to-lymphocyte ratios (NLR) with the gradual recovery of neurological function.

CONCLUSIONS

The expression patterns of T lymphocyte subsets were different in patients with NMDAR-E and viral encephalitis. The changing trends of leukocyte and lymphocyte populations in peripheral blood and cerebrospinal fluid may provide clues for the diagnosis of different types of encephalitides, including NMDARE, and can be used as immunological markers to assess and predict the prognosis.

Analysis of the relation between cerebrospinal fluid antibody titers and clinical characteristics in pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis

OBJECTIVE

This retrospective study aimed to investigate the relationship between cerebrospinal fluid (CSF) antibody titers of N-methyl-d-aspartate receptor (NMDAR), and clinical characteristics in pediatric patients with anti-NMDAR encephalitis.

METHODS

The clinical and laboratory characteristics of hospitalized patients with anti-NMDAR encephalitis, stratified by antibody titers in CSF and disease severity, were retrospectively studied. The demographics, clinical characteristics, main accessory examinations, immunotherapy, and prognosis of patients were recorded, and each observed indicator was statistically analyzed.

RESULTS

A total of 103 pediatric anti-NMDAR encephalitis patients were enrolled in the study, including 41 males (39.8%) and 62 females (60.2%) with a mean age of 8.0 ± 4.0 years. The proportion of patients with cognitive dysfunction and the positive pathogen was higher in the high-titer group than in the low-titer group (p = 0.023, p = 0.042). Consciousness disturbance that occurred as an initial symptom or during the course in the severe group was higher than in the non-severe group (p = 0.002, p < 0.001). More patients in the high-titer group received plasma exchange (PE) than in the low-titer group (p = 0.022). The cure rate of patients was higher with PE (65.2%) than with Corticosteroids and (or) intravenous immunoglobulin (58.1%).

CONCLUSIONS

Patients with symptoms of disturbance of consciousness may be severer. The severity in pediatric anti-NMDAR encephalitis patients was not correlated with anti-NMDAR antibody titers. Patients with high CSF antibody titers had a better prognosis after early PE therapy.

Epilepsy, Immunity and Neuropsychiatric Disorders

Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.

The neutrophil-to-lymphocyte ratio is associated with intubation in pediatric anti-NMDA receptor encephalitis: A retrospective study

Background The neutrophil-to-lymphocyte ratio (NLR) may predict poor outcomes in adult anti-NMDAR encephalitis (NMDARE). The association of NLR with outcomes in pediatric NMDARE was examined. Methods Pediatric NMDARE patients (N = 36) were retrospectively studied. Results High NLR (>6) had a higher proportion of tumors (43% versus 7%) and higher intubation rates (100% versus 38%, p = 0.008). Multivariate analyses showed that high NLR did not correlate with one-year outcomes, inpatient length of stay (LOS), or with tumor, but was associated with intubation and rehabilitation LOS. Conclusion NLR is associated with intubation and rehabilitation LOS. Further investigation is needed for prognostic biomarkers in NMDARE.

The Neutrophil-to-Lymphocyte and Monocyte-to-Lymphocyte Ratios Are Independently Associated With the Severity of Autoimmune Encephalitis

Background

The neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) are biomarkers that may reflect inflammatory status in some immune-related diseases. This study aims to investigate the association of NLR and MLR with the severity and prognosis of autoimmune encephalitis (AE).

Methods

A total of 199 patients diagnosed with AE in the First Affiliated Hospital of Zhengzhou University from October 2015 to October 2021 were retrospectively analyzed. The Clinical Assessment Scale for Autoimmune Encephalitis (CASE) and the modified Rankin Scale (mRS) were used to evaluate the severity of the patients at admission, and the patients were divided into mild group (CASE ≤ 4) and severe group (CASE ≥ 5) according to the CASE score. Poor prognosis was described as an mRS of 3 or more at 12 months. Binary logistic regression analysis was performed to assess risk factors for the severity and prognosis of AE.

Results

NLR and MLR of severe group were significantly higher than that of mild group. NLR and MLR were positively correlated with the CASE score (r = 0.659, P < 0.001; r = 0.533, P < 0.001) and the mRS score (r = 0.609, P < 0.001;r = 0.478, P < 0.001) in AE patients. Multivariate logistic analysis showed that NLR (OR = 1.475, 95%CI: 1.211-1.796, P < 0.001) and MLR (OR = 15.228, 95%CI: 1.654-140.232, P = 0.016) were independent risk factors for the severity of AE. In addition, the CASE score and the mRS score were positively correlated (r = 0.849, P < 0.001). Multivariate logistic analysis showed that the CASE at admission (OR = 1.133, 95%CI: 1.043-1.229, P = 0.003) and age (OR = 1.105, 95%CI: 1.062-1.150, P < 0.001) were independent risk factors for the poor prognosis of AE patients. The NLR and MLR at admission and whether they decreased after immunotherapy were not associated with the prognosis of AE patients (P > 0.05).

Conclusions

NLR and MLR, readily available and widespread inflammatory markers, were helpful for clinicians to monitor disease progression and identify potentially severe patients of AE early to optimize clinical treatment decisions.

High Dose Steroids as First-Line Treatment Increased the Risk of In-Hospital Infections in Patients With Anti-NMDAR Encephalitis

Objective

To address the effects of high dose steroids on in-hospital infection and neurologic outcome in anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis patients.

Methods

We retrospectively reviewed the clinical data of anti-NMDAR encephalitis patients in West China Hospital, the Third Hospital of Mianyang and Mianyang Central Hospital between October 2011 and August 2020. The development of infections, inflammatory factors, neurologic outcome at discharge and risk factors for in-hospital infection were assessed in patients with and without high dose steroid therapy before and after immunotherapy. Least absolute shrinkage and selection operator (LASSO) regression and logistic regression models were established to assess risk factors for in-hospital infection.

Results

A total of 278 patients with anti-NMDAR encephalitis were included in the study. Thirty-four patients received high dose methylprednisolone (IVMP) therapy only, 84 patients received intravenous immunoglobulin (IVIG) therapy, and 160 patients received IVIG and IVMP therapy. Compared with the IVIG group, IVIG + IVMP group had a higher infection rate (64.38% vs 39.29%, P < 0.001), a higher incidence of noninfectious complications (76.25% vs 61.90%, P = 0.018) and a higher modified Rankin Scale (mRS) score at discharge from the hospital (3 vs 2, P < 0.001). Inflammatory indicators, including white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII), were higher (9.93 vs 5.65, 6.94 vs 3.47 and 1.47 vs 0.70, respectively, P < 0.001) in the IVIG + IVMP group than in the IVIG group. Moreover, lymphocyte-to-monocyte ratio (LMR) was lower (2.20 vs 2.54, P = 0.047) in the IVIG + IVMP group. The LASSO model showed that mRS score on admission, seizure, body temperature, uric acid (URIC), cerebrospinal fluid immunoglobulin G (CSF IgG), NLR and LMR were risk factors for in-hospital infection. The prediction model exhibited an area under the curve (AUC) of 0.885.

Conclusions

High dose steroids therapy was significantly associated with higher in-hospital infectious complication rates and a poor short-term prognosis in relatively severe anti-NMDAR encephalitis patients. The established prediction model might be helpful to reduce the risk of in-hospital infection.