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Vervloet Sollero CE, Piquet AL, Robinson C, Gyang TV, Carlson A. Anti-NMDA Receptor Encephalitis Related to Renal Cell Carcinoma: A Case Report. Neurohospitalist 2024; 14:189-194. [PMID: 38666271 PMCID: PMC11040629 DOI: 10.1177/19418744231216179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Anti-NMDA receptor (NMDAR) encephalitis is characterized by a well-defined neuropsychiatric syndrome and CSF antibodies against the GluN1 subunit of the NMDAR. 40% of cases are related to underlying tumors, the vast majority ovarian teratomas (94%). We report a case of anti-NMDAR encephalitis associated with renal cell carcinoma (RCC). A 20-year-old female presented to the ED with behavioral changes, involuntary movements, tachycardia, and alternating obtundation with agitation which progressed over 3 weeks. Involuntary movements were severe, requiring intubation and sedation for control, and were accompanied by rhabdomyolysis. Brain MRI showed bilateral mesiotemporal T2/FLAIR hyperintensities. Anti-NMDAR antibodies were present in the serum (1:640) and CSF (1:320). Malignancy screening revealed a renal mass concerning for RCC, which was confirmed upon resection. She was started on high dose IV methylprednisolone and plasmapheresis, followed by rituximab. Lack of response led to escalating immunotherapy with cyclophosphamide. Clinical course was complicated by prolonged ICU admission, prolonged sedation, severe dysautonomia and bacteremia. Improvement began 2 months after immunotherapy, and she was discharged to rehabilitation 100 days after admission with mild neuropsychiatric symptoms. Repeat malignancy screenings, including whole-body imaging and transvaginal ultrasound were consistently negative. Herein, we describe a case of definite anti-NMDAR encephalitis in the setting of newly diagnosed RCC. This case illustrates how tumors other than ovarian teratomas may act as immunological triggers, as well as the complex and prolonged symptomatic and immunosuppressive therapies required in severe presentations of anti-NMDAR encephalitis.
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Affiliation(s)
| | - Amanda L Piquet
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Christopher Robinson
- Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL, USA
| | | | - Aaron Carlson
- Department of Neurology, University of Colorado, Aurora, CO, USA
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Qin M, Chen J, Guo X, Xiang X, Nie L, Wang Y, Mao L. Movement disorders in autoimmune encephalitis: an update. J Neurol 2023; 270:5288-5302. [PMID: 37523063 DOI: 10.1007/s00415-023-11881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis (AE) is a form of encephalitis resulting from an immune response targeting central nervous system antigens, which is characterized by cognitive impairment, neuropsychiatric symptoms, seizures, movement disorders (MDs), and other encephalopathy symptoms. MDs frequently manifest throughout the progression of the disease, with recurrent involuntary movements leading to discomfort and, in some cases, necessitating admission to the intensive care unit. Prompt identification and management of MDs can aid in the diagnosis and prognosis of AE. This review synthesizes current knowledge on the characteristics, underlying mechanisms, and treatment options for MDs in the context of AE.
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Affiliation(s)
- Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Zhang Y, Cui L, Chen W, Huang H, Liu G, Su Y, Boltze J. Status dystonicus in adult patients with anti-N-methyl-D-aspartate-acid receptor encephalitis. J Neurol 2023; 270:2693-2701. [PMID: 36810828 DOI: 10.1007/s00415-023-11599-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Status dystonicus (SD) is a severe movement disorder (MD) and has rarely been recognized in anti-N-methyl-D-aspartate-acid receptor (NMDAR) encephalitis, particularly in adult patients. We aim to explore the clinical characteristics and outcome of SD in anti-NMDAR encephalitis. METHODS Patients with anti-NMDAR encephalitis admitted to Xuanwu Hospital from July 2013 to December 2019 were prospectively enrolled. SD was diagnosed based on the patients' clinical manifestations and video EEG monitoring. Outcome was evaluated 6 and 12 months after enrollment using the modified Ranking Scale (mRS). RESULTS A total of 172 patients with anti-NMDAR encephalitis, including 95 males (55.2%) and 77 females (44.8%) with a median age of 26 years (interquartile range 19 to 34) were enrolled. Eighty patients (46.5%) presented with movement disorder (MD), 14 of whom suffered from SD, which manifested as chorea (14/14, 100%), orofacial dyskinesia (12/14, 85.7%), generalized dystonia (8/14, 57.1%), tremor (8/14, 57.1%), stereotypies (5/14, 35.7%), and catatonia (1/14, 7.1%) of the trunk and limbs. All SD patients exhibited disturbed consciousness and central hypoventilation, requiring intensive care. SD patients also had high cerebrospinal fluid NMDAR antibody titers, a higher proportion of ovarian teratoma, higher mRS scores upon enrollment, longer duration to recover, and poorer outcomes at 6 (P < 0.05) but not at 12 months as compared to non-SD patients. CONCLUSION SD is not uncommon in anti-NMDAR encephalitis patients and relates to the severity and worse short-term outcome of the anti-NMDAR encephalitis. Early recognition of SD and timely treatment is important to shorten the time needed for recuperation.
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Affiliation(s)
- Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
- Institute of Sleep and Consciousness Disorders, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, CV4 7AL, UK.
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Stephen CD, Schaefer PW, Appleby BS, Oakley DH. Case 5-2022: A 65-Year-Old Woman with Rapidly Progressive Weakness in the Right Arm and Recurrent Falls. N Engl J Med 2022; 386:674-687. [PMID: 35172059 DOI: 10.1056/nejmcpc2115852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Christopher D Stephen
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Pamela W Schaefer
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Brian S Appleby
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Derek H Oakley
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
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Hutchinson ML, Yeshokumar AK, Armangue T. Antibody-Mediated Encephalitis in Children: Focus on Diagnostic Clues and Acute Symptom Management. Semin Pediatr Neurol 2021; 37:100873. [PMID: 33892846 DOI: 10.1016/j.spen.2021.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 01/18/2023]
Abstract
Antibody-mediated encephalitis is a treatable cause of encephalitis that manifests over days to weeks as changes in behavior and cognition, seizures, movement disorders, and autonomic dysfunction. Patients with autoimmune encephalitis develop a variety of symptoms. As such, they require a multidisciplinary approach to care. In this review we summarize the clinical presentation and practical diagnostic approach to pediatric autoimmune encephalitis, review treatments of the autoimmune process, and discuss the management of the acute symptoms encountered in children.
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Affiliation(s)
| | - Anusha K Yeshokumar
- Departments of Neurology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain
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Paraneoplastic and autoimmune encephalitis: Alterations of mood and emotion. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:221-234. [PMID: 34389119 DOI: 10.1016/b978-0-12-822290-4.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis often produces signs and symptoms that appear to be at the interface between neurology and psychiatry. Since psychiatric symptoms are often prominent, patients are often first seen in a psychiatric setting. Therefore it is important that psychiatrists, as well as neurologists, be able to recognize autoimmune encephalitis, a task that is often difficult. Early diagnosis of autoimmune encephalitis is crucial as this will usually result in a better outcome for the patient. This chapter provides an introduction to various autoimmune encephalitides and describes their pathophysiology and the possible associated neuropsychiatric, neuropsychological (cognitive), and neurological (sensory-motor) signs and symptoms. This chapter also reviews the possible treatments of these associated signs and symptoms.
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