Anti-NMDA receptor encephalitis. The disorder, the diagnosis and the immunobiology

Recurrent anti-NMDA receptor encephalitis in first-trimester pregnancy with initially antibody-negative CSF

Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a paraneoplastic autoimmune encephalomyelitis that predominantly affects females in their reproductive years Dalmau et al., 2007 and Dalmau et al., 2019. It has been infrequently reported during pregnancy Dono et al., 2023 and Joubert et al., 2020. We describe a case of a 25-year-old G4P2 patient at 11 weeks gestation with a history of anti-NMDAR encephalitis who presented with intermittent confusion for two weeks. Initial antibody tests for anti-NMDAR encephalitis in the cerebrospinal fluid (CSF) were negative. Repeat serum labs drawn upon readmission to the emergency department (ED) 3 weeks later were positive, and results were confirmed with repeat CSF testing. Following treatment, the patient returned to baseline and delivered a developmentally healthy, full-term baby. Current gold-standard testing for anti-NMDAR encephalitis is through detection of NMDAR antibodies in the CSF Gresa-Arribas et al., 2014. However, CSF antibody testing early in the disease course may not be as sensitive as traditionally thought, and repeat testing is indicated if high suspicion continues.

Comparison of mNGS with conventional methods for diagnosis of cryptococcal meningitis: a retrospective study

The application of metagenomic next-generation sequencing (mNGS) in the diagnosis of cryptococcal meningitis is relatively under characterized. Here, we retrospectively evaluated data from cryptococcal meningitis patients who were tested using mNGS and/or routine testing, including fungal culture, India ink staining, and cryptococcal antigen (CrAg) testing. The performance of mNGS was then assessed. Initial cerebrospinal fluid (CSF) samples were collected from 65 patients with suspected central nervous system (CNS) infection and tested using conventional tests and/or mNGS. mNGS offers a culture-independent approach, facilitating a rapid and unbiased detection of a broad spectrum of pathogens. Patients with bacterial tuberculous or viral meningitis were used as mNGS-positive controls and one autoimmune encephalitis patient was used as an mNGS-negative control. In the 45 patients diagnosed with cryptococcal meningitis, the sensitivity, specificity, positive predictive value, negative predictive value, and concordance rate of mNGS were 92%, 100%, 100%, 90.9%, and 95.6%, respectively. Compared to conventional methods, the sensitivity of mNGS was slightly lower than CrAg tests (96.7%) but higher than India ink (79.5%) and culturing (63.4%). Of the two negative mNGS cases (2/25, 8.0%), one was positive by India ink staining, culture, and CrAg testing, while the other was positive only by CrAg testing. A combination of mNGS and conventional methods enhanced the detection rate to 100%. Our study demonstrates that both CrAg and mNGS offer excellent diagnostic accuracy for cryptococcal meningitis, and utilizing both tests can enhance clinical assessment and patient management.

DPPX antibody-mediated disease mimicking Wernicke's encephalopathy

Anti-dipeptidyl-peptidase-like protein 6 antibody-mediated disease is a rare autoimmune encephalitis typically presenting with diarrhoea and/or weight loss, central nervous system hyperexcitability and cognitive dysfunction. We present a case of a young woman with 10 days of diplopia and unsteadiness in the context of dysthymia and significant weight loss over 2 months. Initial examination demonstrated mixed dysconjugate nystagmus and ataxic gait. Presumed diagnosis was Wernicke's encephalopathy and intravenous thiamine was given, resulting in partial improvement. Subsequent examination revealed hyperekplexia with ocular flutter, cervical dystonia and startle myoclonus. Cerebrospinal fluid indirect immunofluorescence on primate cerebellum revealed granular layer pattern of staining, prompting testing for anti-dipeptidyl-peptidase-like protein antibodies, which returned strongly positive. Given the phenotypic overlap, it is important to consider this rare disorder in the differential diagnosis of Wernicke's encephalopathy. In this case, the emergence of ocular flutter, startle myoclonus and the specific type of nystagmus made it clear there was an alternative diagnosis.

Increased serum phenylalanine/tyrosine ratio associated with the psychiatric symptom of anti-NMDAR encephalitis

Background

Encephalitis associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR) results in a distinctive neuro-psychiatric syndrome. It has been reported that the serum phenylalanine-tyrosine (Phe/Tyr) ratio increases during infection. However, the connection between phenylalanine-tyrosine metabolism and psychiatric symptoms remains unclear.

Methods

We enrolled 24 individuals with anti-NMDAR encephalitis and 18 individuals with non-inflammatory neurological diseases (OND). Chromatography was used to measure serum levels of phenylalanine and tyrosine. Serum and cerebrospinal fluid (CSF) TNF-α levels were obtained from the clinical database. The modified Rankin Scale (mRS) score and Glasgow Coma Scale (GCS) score were recorded during the acute phase. The area under the curve (AUC) of the receiver operating characteristic curve was used to assess prediction efficacy.

Results

In NMDAR patients, levels of serum Phe and the ratio of serum Phe/Tyr were higher compared to OND patients. The serum Phe/Tyr ratio was also elevated in NMDAR patients with psychiatric syndrome. Furthermore, serum Phe and Tyr levels were correlated with inflammatory indexes.

Conclusion

The serum Phe/Tyr ratio is elevated in NMDAR patients with psychiatric syndrome and is associated with severity. Therefore, the serum Phe/Tyr ratio may serve as a potential prognostic biomarker.

Clinical features of adult patients with positive NMDAR-IgG coexisting with MOG-IgG

INTRODUCTION

This study was designed to analyze clinical and radiographic features of adult patients coexisting with NMDAR-IgG and MOG-IgG.

METHODS

Eleven adult patients coexisting with NMDAR-IgG and MOG-IgG were collected from Xiangya Hospital, Central South University, between June 2017 and December 2021. Fifty-five patients with anti-NMDAR encephalitis and 49 with MOG-AD were served as controls.

RESULTS

Onset age was 27 (IQR 20-34) years old. Seizures and psychotic symptoms were prominent symptoms. Ten of eleven patients presented abnormal T2/FLAIR hyperintensity, mainly involving the cortex, brainstem, and optic nerve. Compared with the NMDAR IgG ( +)/MOG IgG ( -) group, the NMDAR IgG ( +)/MOG IgG ( +) group showed more ataxia symptoms (27.3% vs. 3.6%, P = 0.037), while more T2/FLAIR hyperintensity lesions were found in the brainstem (54.5% vs. 7.3%, P < 0.001) and optic nerve (27.3% vs. 1.8%, P = 0.011) with more abnormal MRI patterns (90.9% vs. 41.8%, P = 0.003). In comparison with the NMDAR IgG ( -)/MOG IgG ( +) group, the NMDAR IgG ( +)/MOG IgG ( +) group had more seizures (72.7% vs. 24.5%, P = 0.007) and mental symptoms (45.5% vs. 0, P < 0.001). The NMDAR IgG ( +)/MOG IgG ( +) group tended to be treated with corticosteroids alone (63.6% vs. 20.0%, P = 0.009), more prone to recur (36.5% vs. 7.3%, P = 0.028) and lower mRS score (P = 0.036) at the last follow-up than pure anti-NMDAR encephalitis.

CONCLUSION

The symptoms of the NMDAR IgG ( +)/MOG IgG ( +) group were more similar to anti-NMDAR encephalitis, while MRI patterns overlapped more with MOG-AD. Detecting both NMDAR-IgG and MOG-IgG maybe warranted in patients with atypical encephalitis symptoms and demyelinating lesions in infratentorial regions.

A case of NMDAR Encephalitis with muscular pain as the main presentation

BACKGROUND

Persistent somatoform pain disorder (PSPD) is often the initial diagnosis in patients seeking treatment in psychiatric departments, making it challenging to consider organic nervous system diseases. However, autoimmune encephalitis can present with atypical initial symptoms, leading to misdiagnosis or missed diagnosis. Lumbar puncture, with antibody support, plays a crucial role in diagnosing autoimmune encephalitis.

CASE PRESENTATION

This report describes a 40-year-old male adult patient who was initially diagnosed with persistent somatoform pain disorder in 2022. The patient reported a reduction in pain while resting on his back. There were no fever or relevant medical history. Despite 8 months of symptomatic treatment, the symptoms did not improve. Moreover, the patient developed confusion, gibberish speech, non-cooperation during questioning, and increased frequency and amplitude of upper limb convulsions. Lumbar puncture revealed elevated protein levels and protein-cell dissociation. The autoimmune encephalitis antibody NMDAR (+) was detected, leading to a diagnosis of autoimmune encephalitis (NMDAR).

CONCLUSION

Autoimmune encephalitis (NMDAR), starting with persistent somatoform pain (PSPD), often presents with atypical symptoms and can be easily misdiagnosed. Therefore, it is important to consider the possibility of organic nervous system disease in time, and to test serum or cerebrospinal fluid antibodies to rule out organic nervous system disease after symptomatic treatment of mental disorders is ineffective. This approach facilitates the early diagnosis of autoimmune encephalitis and other underlying organic neurological disorders.

An Adolescent Presenting With Mania and Catatonia Associated With Coronavirus Disease-2019 Encephalitis

There is growing evidence that coronavirus disease-2019 (COVID-19) infection may have various neuropsychiatric manifestations and long-term outcomes. In this article, the authors report a rare case of a 16-year-old male with no previous history of psychiatric illness who presented with an acute manic episode, including laughing for no evident reason, talking to himself, isolation, irritability, sleeplessness, decreased appetite, prolonged staring episodes, having delusions about being harmed or controlled, and aggression. Despite initiating outpatient treatment with a mood stabilizer and antipsychotic for presumed bipolar disorder with psychotic features, his symptoms worsened, and he became catatonic with a decreased level of consciousness, leading to his hospitalization on day 10. Although he had not shown typical evidence of infection with COVID-19 in the days leading up to or during his hospitalization and his initial COVID-19 test was negative, his COVID-19 test was positive on day 14, and his chest X-ray showed infiltrations. His acute manic symptoms and catatonia were identified to be associated with COVID-19 encephalitis after excluding other causes. He responded well to treatment with lorazepam for catatonia and a course of intravenous immunoglobulin, methylprednisolone, and remdesivir for COVID-19 encephalitis. This case demonstrates the workup and treatment of a rare neuropsychiatric manifestation of COVID-19 encephalitis in an adolescent, which started with no past psychiatric history and no typical symptoms of COVID-19 infection.

Anti-N-methyl-D-aspartate receptor encephalitis and positive human herpesvirus-7 deoxyribonucleic acid in cerebrospinal fluid: a case report

BACKGROUND

Anti-N-methyl-D-aspartate receptor encephalitis is a neuroautoimmune syndrome typically presenting with seizures, psychiatric symptoms, and autonomic dysfunction. Human herpesvirus-7 is often found with human herpesvirus-6 and infects leukocytes such as T-cells, monocytes-macrophages, epithelial cells, and central nervous system cells. The pathogenicity of human herpesvirus-7 is unclear. Cases of anti-N-methyl-D-aspartate receptor encephalitis with human herpesvirus-7 present in cerebrospinal fluid have been documented, but the clinical significance of this finding remains unclear.

CASE PRESENTATION

An 11-year-old Caucasian boy was admitted to hospital after a generalized tonic-clonic seizure. Generalized tonic seizures repeated three more times during the day of hospitalization. Blood tests showed minor ongoing inflammation, while brain computed tomography yielded normal results. Brain magnetic resonance imaging showed hyperintense focal alterations in both temporal lobes, hippocampi, and at the base of the right frontal lobe. Positive anti-N-methyl-D-aspartate receptor antibodies were found in both serum and cerebrospinal fluid. Positive novel coronavirus 2 (severe acute respiratory syndrome coronavirus 2) immunoglobulin G antibodies were found in serum. Polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 was negative. Furthermore, positive human herpesvirus-7 deoxyribonucleic acid was found in cerebrospinal fluid. The patient was treated with acyclovir, human immunoglobulin, and methylprednisolone. The seizures did not repeat, and no psychiatric symptoms were present. The patient made a full recovery.

CONCLUSIONS

We present a pediatric case of anti-N-methyl-D-aspartate receptor encephalitis with atypical clinical presentation. The role of human herpesvirus-7 in neurological disorders remains unclear in immunocompetent patients.

Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children

Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.

Neurosyphilis with positive anti-N-methyl-D-aspartate receptor antibody: a case report

A case of neurosyphilis with a positive anti-N-methyl-D-aspartate receptor (NMDAR) antibody was reported. A 54-year-old man who presented with acute memory deficits was admitted to our hospital. Acute ischemic stroke (AIS) was initially considered, and he was prescribed intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA). However, the intermittent onset of episodic memory and orientation disorder still occurred. No diffusion restriction was indicated by magnetic resonance imaging (MRI), and subclinical seizures were frequently found by electroencephalogram (EEG). Rapid plasma reagin (RPR) test of serum showed positive results for syphilis. Analysis of cerebrospinal fluid (CSF) revealed elevated leukocyte count and protein level. RPR test, Treponema pallidum particle agglutination (TPPA) assay, and Treponema pallidum antibody (TP-Ab) in CSF showed positive results, and the anti-NMDAR antibodies were positive in CSF and serum. Finally, the patient was diagnosed with neurosyphilis with a positive anti-NMDAR antibody. The clinical symptoms were improved, and the leukocyte count in CSF was reduced after treatment with intravenous penicillin G and levetiracetam. This case suggests that in cases with positive results for neurosyphilis and NMDAR antibodies, the proper treatment has to be decided based on all of the available clinical and diagnostic testing data.

Anti-N-methyl-D-aspartate receptor encephalitis in pregnancy associated with teratoma

A 36-year-old pregnant woman with a prior history of depression and recent gunshot wounds presented with sudden deterioration in her mental status. Clinical examination revealed psychosis, hallucinations, and lack of orientation, with an otherwise normal neurological and cardiorespiratory examination. Computed tomographic scan of her head was normal, and she was diagnosed with acute psychosis and excited delirium. She did not respond to supraphysiologic dosages of antipsychotic therapy and needed physical restraints for combativeness and agitation. Her cerebrospinal fluid analysis was negative for an infectious etiology, but was positive for anti-N-methyl-D-aspartate receptor encephalitis antibodies. Abdominal imaging revealed a right-sided ovarian cyst. Subsequently she underwent right-sided oophorectomy. Postoperatively the patient continued to have intermittent episodes of agitation requiring antipsychotic medications. Later, she was safely transitioned to home care with family support.

Brain magnetic resonance imaging predictors in anti-N-methyl-D-aspartate receptor encephalitis

OBJECTIVE

Brain magnetic resonance imaging (MRI) findings in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are nonspecific and rarely have obvious associations with clinical characteristics and outcomes. This study aimed to comprehensively describe the MRI features of patients with NMDAR encephalitis, examine their associations with clinical characteristics, and evaluate their predictive power for disease recurrence and prognosis.

METHODS

We retrospectively extracted the clinical data and brain MRI findings of 144 patients with NMDAR encephalitis. Patients underwent a 2-year follow-up to assess disease outcomes. We evaluated the associations of brain MRI findings at the onset with clinical characteristics, recurrence, and prognosis.

RESULTS

Initial MRI showed typical abnormalities in 65 patients (45.1%); of these, 34 (29.3%) developed recurrence and 10 (9.4%) had poor prognosis (mRS ≥3). Binary logistic regression analyses revealed that insula abnormalities were associated with acute seizure (odds ratio [OR] = 3.048, 95% confidence interval [CI]: 1.026-9.060) and white matter lesions were associated with cognitive impairment (OR = 2.730, 95% CI: 1.096-6.799). Risk factors for a poor 2-year prognosis included a higher number of brain MRI abnormalities (OR = 1.573, 95% CI: 1.129-2.192) and intensive care unit (ICU) admissions (OR = 15.312, 95% CI: 1.684-139.198). The risk factors for 2-year recurrence included abnormalities of the thalamus (HR = 3.780, 95% CI: 1.642-8.699).

INTERPRETATIONS

Brain MRI features of patients with NMDAR encephalitis were associated with clinical manifestations, prognosis, and recurrence. Higher numbers of MRI abnormalities and ICU admissions were predictive of poor prognosis. Abnormalities of the thalamus constituted a recurrence-related risk factor.

Autoimmune encephalitis after herpes simplex encephalitis: A still undefined condition

Herpes simplex encephalitis (HSE) is one of the most common sporadic viral encephalitis. Generally, HSE is characterized by a monophasic short course, although in some patients neurological relapses or worsening of deficits can develop some weeks later, when viral therapy has been discontinued and signs and symptoms of the central nervous system (CNS) damage seem to have stabilized. The second HSE stage is generally identified as autoimmune encephalitis after HSE (AEaHSE). Aim of this paper is to discuss which are the present knowledge in this regard. Literature analysis showed that AEaHSE exists, it is more common in younger children and it has different clinical manifestations according to age. All the patients with AEaHSE are positive for one or more neuronal cell-surface and synaptic antibodies, mainly anti-NMDAR antibodies, and the earlier the appearance of the antibodies the greater the risk of AEaHSE development. This means that a careful monitoring of antibody production starting from anti-NMDAR antibodies in all HSE cases could lead to the early identification of AEaHSE and the prompt administration of a potentially effective therapy. Further studies are needed to clarify which are the main pathogenetic mechanisms, whether there are differences in risk of development and clinical course of AEaHSE according to the type of antibody production, why response to immunosuppressive therapy significantly varies and whether administration of steroids to patients with HSE during the first phase of disease can play a role for reducing the risk of AEaHSE development.

Conformation-stabilizing ELISA and cell-based assays reveal patient subgroups targeting three different epitopes of AGO1 antibodies

Autoantibodies (Abs) are biomarkers for many disease conditions and are increasingly used to facilitate diagnosis and treatment decisions. To guarantee high sensitivity and specificity, the choice of their detection method is crucial. Via cell-based assays, we recently found 21 patients with neurological diseases positive for antibodies against argonaute (AGO), 10 of which having a neuropathy (NP). Here, we established a simple and conformation-sensitive ELISA with the aim to distinguish between AGO1 Abs against conformational epitopes and non-conformational epitopes and to reveal further characteristics of AGO1 antibodies in NP and autoimmune disease (AID). In a retrospective multicenter case/control and observational study, we tested 434 patients with NP, 274 disease controls with AID, and 116 healthy controls (HC) for AGO1 Abs via conformation-stabilizing ELISA. Seropositive patients were also tested for conformation-specificity via comparative denaturing/stabilizing ELISA (CODES-ELISA), CBA positivity, AGO1 titers and IgG subclasses, and AGO2 reactivity. These parameters were statistically compared among different epitope-specific patient groups. We found Abs in 44 patients, including 28/434 (6.5%) NP, 16/274 (5.8%) AID, and 0/116 (0%) HC. Serum reactivity was consistently higher for AGO1 than AGO2. Globally among the 44 AGO1 Abs-positive patients, 42 were also tested in CBA for AGO1 Abs positivity and 15 (35.7%) were positive. Furthermore, 43 were tested for conformation-specificity and 32 (74.4%) bound a conformational epitope. Among the subgroups of highly positive patients (ELISA z-score >14) with sera binding conformational epitopes (n=23), 14 patient sera were also CBA positive and 9 bound a second conformational but CBA-inaccessible epitope. A third, non-conformational epitope was bound by 11/43 (15.6%). Among the epitope-specific patient subgroups, we found significant differences regarding the Abs titers, IgG subclass, and AGO2 reactivity. When comparing AGO1 Abs-positive NP versus AID patients, we found the conformation-specific and CBA inaccessible epitope significantly more frequently in AID patients. We conclude that 1) conformational ELISA was more sensitive than CBA in detecting AGO1 Abs, 2) serum reactivity is higher for AGO1 than for AGO2 at least for NP patients, 3) AGO1 Abs might be a marker-of-interest in 6.5% of NP patients, 4) distinguishing epitopes might help finding different patient subgroups.

Evaluating the incidence and predictors of anti-NMDAR encephalitis in a contemporary cohort of patients diagnosed with dermoid tumors: A national inpatient sample analysis

INTRODUCTION

Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a form of encephalitis previously associated with dermoid tumors. However, most studies in the literature evaluating the disease are case reports and small patient cohorts, limiting robust statistical analysis. Here, we demonstrate predictors of anti-NMDAR encephalitis in a large cohort of US patients.

METHODS

We used the 2016 National Inpatient Sample (NIS) to identify a cohort of 24,270 admitted for an ovarian dermoid tumor. Of these patients, 50 (0.21%) were diagnosed with anti-NMDAR encephalitis. Patient demographics, hospital characteristics, length of stay (LOS), and complications were collected. Statistical analysis consisted of odds ratios with chi-square testing to compare categorical variables.

RESULTS

The mean age of all patients with dermoid tumors was 45.5 ± 18.0 years, and the mean age of patients with diagnosed anti-NMDAR encephalitis was 27.4 ± 4.9 years. The mean LOS in the dermoid tumor cohort was 3.5 ± 4.9 days, while the mean LOS in the anti-NMDAR encephalitis cohort was 31.9 ± 25.9 days (p < 0.001). The mean cost in the dermoid tumor cohort was $44,813.18±$54,305.90, while the mean cost in the anti-NMDAR encephalitis cohort was $445,628.60±$665,423.40 (p < 0.001). Patients with age above 30 years with dermoid tumors had significantly lower odds of developing anti-NMDAR encephalitis compared to patients younger than 30 years (OR: 0.19; 95%CI: 0.045-0.67; p-value: 0.003). White patients had significantly lower odds of developing anti-NMDAR encephalitis (OR: 0.19; 95%CI: 0.026-0.77; p-value: 0.013), and Black patients had significantly higher odds of developing anti-NMDAR encephalitis (OR: 3.45; 95%CI: 1.00-12.46; p-value: 0.044).

CONCLUSION

Patient predictors of developing anti-NMDAR encephalitis include age, race, ethnicity and patients who go on to develop anti-NMDAR encephalitis have a significantly increased hospital LOS and cost compared to those who do not. Future research, including multi-center clinical trials and longitudinal data, is necessary to fully cement the findings of this manuscript.

Anti-NMDA Receptor Encephalitis: Retrospective Analysis of 15 Cases, Literature Review, and Implications for Gynecologists

Background

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a rare form of autoimmune encephalitis caused by anti-NMDA receptor antibodies. This disease mainly affects women of childbearing age and is commonly associated with ovarian teratoma. However, the relationship between anti-NMDA receptor encephalitis and ovarian teratoma and the role of anti-NMDA receptor antibody in the relationship remain unclear.

Objectives

This study aimed to describe 15 cases of anti-NMDA receptor encephalitis (5 with ovarian teratoma), review literature, and reinforce the gynecologist's knowledge of this disorder.

Methods

Clinical data of 15 patients from January 2015 to December 2020 admitted to The Second Hospital of Hebei Medical University were collected and analyzed. The diagnosis of anti-NMDA receptor encephalitis was based on the presence of anti-NMDA receptor antibodies in cerebrospinal fluid (CSF) and/or serum. Laparoscopic teratoma removal was performed in patients with ovarian teratoma. All patients had received immunotherapy. In addition, a review of the literature was performed to reinforce the gynecologist's knowledge of this disorder.

Results

A total of 15 patients with anti-NMDA receptor encephalitis were screened, of whom 5 patients were confirmed with ovarian teratoma by pathology. The most common symptoms of anti-NMDAR encephalitis with teratoma are fever (5/5, 100%), seizure (5/5, 100%), mental and behavioral disorders (4/5, 80%), and decreased consciousness (4/5, 80%). Conversely, the most common symptoms of patients without teratoma were neuropsychiatric symptoms, including headache (6/10, 60%) and mental and behavioral disorders (7/10, 70%). All patients underwent immunotherapy, including steroids, intravenous immunoglobulin (IVIG), plasma exchange, and cyclophosphamide, and 4 out of 5 patients with ovarian teratomas underwent surgical treatment. All patients had a good outcome after systemic, surgical, and immunotherapy treatment. No patient who underwent surgical treatment developed a recurrence. Conversely, 2 of 10 patients without teratoma developed an anti-NMDA receptor encephalitis recurrence.

Conclusions

Patients with anti-NMDA encephalitis show severe mental and neurological symptoms. Resection of teratoma is beneficial to the relief or disappearance of symptoms and has a good prognosis. This disorder should be fully recognized by gynecologists, who play an important role in diagnosis and treatment.

Relapse factors of patients of anti-N-methyl-D-aspartate receptor encephalitis

BACKGROUND

The factors associated with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis relapse are yet to be elucidated.

AIMS OF THE STUDY

To investigate the factors associated with relapse and prognosis of anti-NMDA receptor encephalitis.

METHODS

This retrospective study included patients diagnosed with anti-NMDA receptor encephalitis admitted to the First Affiliated Hospital of Zhengzhou University from January 2013 to October 2019. The clinical features, auxiliary examinations, treatment regimens, and follow-up were recorded. The outcomes were relapse and 2-year disease prognosis.

RESULTS

A total of 160 patients were included. Consequently, 6 (5%) deaths, 34 (25.4%) relapses, and 19 (15.2%) patients had a poor prognosis (modified Rankin score (mRS) ≥3) were recorded. The multivariable analyses showed that age (p = .011), abnormal magnetic resonance imaging (MRI) (p = .019), glucocorticoid pulse (p = .009), and intracranial pressure (p = .023) were independently associated with the relapse, while age (p = .030) and central hypoventilation (p = .020) were independently associated with a poor prognosis at 2 years.

CONCLUSION

Glucocorticoid pulse therapy reduces the relapse of anti-NMDA receptor encephalitis. Age, abnormal MRI, and intracranial pressure are risk factors for relapse, while age and central hypoventilation are independently associated with poor prognosis.

Acute psychiatric symptoms in a young woman with anti-N-methyl D-aspartate receptor encephalitis: A case of successful early diagnosis and therapeutic intervention

This clinical image presents a report on the diagnosis and treatment of anti-NMDAR encephalitis, a rare disease. This report emphasizes the importance of a differential diagnosis for acute psychiatric symptoms. Accurate and timely diagnosis is critical for the selection and implementation of treatment and for optimal patient outcomes.

Case Analysis and Literature Review of Thirteen Patients with Autoimmune Encephalitis

Objective. To investigate the clinical manifestations, laboratory and imaging examinations, and the treatment outcomes of autoimmune encephalitis (AE). Methods. The clinical data of 13 patients with autoimmune encephalitis who were hospitalized in the department of neurology, Liaocheng People’s Hospital from July 2016 to August 2018 were retrospectively analyzed. Results. The average age of onset of the 13 patients was 45 years, including 6 cases (46%) of anti-NMDAR encephalitis, 3 cases (23%) of anti-GABAB receptor encephalitis, and 4 cases (30%) of anti-LG11 encephalitis, and 4 of them showed abnormal signals of brain MRI (30%). 13 patients (100%) had cognitive impairment and psychiatric symptoms; seizures occurred in 12 patients (92%); lung cancer was found in 1 patient (7%). One case was given up because of the treatment of lung cancer, the other was controlled obviously in epilepsy, and cognitive impairment and abnormal mental behavior were also significantly improved. Conclusion. Patients with AE still need to be diagnosed early to avoid missed diagnosis and receive early immunosuppressive therapy, which could effectively reduce mortality and morbidity. A detailed history, clinical manifestations, and positive results for specific NSAbs tests can confirm the diagnosis, and the treatment is mainly done by immunosuppressive therapy.

Case Report: Cotard's Syndrome in Anti-N-methyl D-aspartate (NMDA) Receptor (Anti-NMDAR) Encephalitis

Cotard's syndrome is uncommon psychopathology among patients with psychotic illnesses. Limited cases had been reported regarding the occurrence of this syndrome in anti-NMDAR encephalitis which itself is a relatively new disease that often presents with florid psychotic symptoms. This poses difficulties in differentiating it from a primary psychiatric illness. Late recognition of anti-NMDAR encephalitis can lead to death as it can progress to autonomic instability in its natural course of illness. We report a patient who first presented with psychotic symptoms with initial negative findings from baseline investigations. Further investigation revealed anti NMDAR antibodies in the cerebrospinal fluid. Prompt treatment was initiated and despite early poor response to the first-line treatment with the development of allergic reaction, our patient recovered completely after 1 month of hospitalization. This case report aims to highlight the importance of early detection of anti-NMDAR encephalitis and the possibility of uncommon psychopathology such as Cotard's syndrome occurring in this disease.

Prevention of oral and maxillofacial trauma secondary to orofacial dyskinesias associated with anti-N-methyl-D-aspartate receptor encephalitis: a case series

Background

Anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is a multi-stage autoimmune-mediated disease associated with a multitude of neuropsychiatric and dysautonomic features. Orofacial dyskinesias are frequently associated with this condition and manifest as abnormal movements of the orofacial musculature. These involuntary movements may result in significant trauma to the oral and maxillofacial complex including the avulsion of the dentition and orofacial lacerations.

Case presentation

We describe the course of two female patients with anti-NMDARE in whom significant involuntary self-inflicted maxillofacial trauma was suffered despite the use of complex parenteral sedation regimens. The application of traditional maxillomandibular wiring techniques and pharmacologic strategies, including botulinum toxin, to immobilize the mandible were initially unsuccessful. These difficulties led to the fabrication and wire-based fixation of a patient-specific acrylic oral appliance that maintained the mandible in a depressed position and mitigated all lateral and protrusive movements.

Discussion and conclusions

These cases illustrate the first known successful use of an appliance-based therapy for managing orofacial dyskinesias in the anti-NMDARE patient population through an adaptation of traditional maxillomandibular fixation techniques. This approach eliminated further orofacial trauma and afforded physicians with safer means to manage and assess patients afflicted with this condition during their protracted intensive care unit admissions.

Temporal rank of clinical characteristics and prognosis of anti-N-methyl-d-aspartate receptor encephalitis

OBJECTIVES

Early recognition and intervention of patients with the anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis are important to achieve a better prognosis. The study aims to summarize the real-world perspectives of anti-NMDAR encephalitis patients in China via electronic medical records (EMRs).

METHODS

Using EMRs of patients from 2013 to 2019 from West China Hospital in China, a retrospective research was conducted to demonstrate the temporary rank of clinical characteristics and disease prognosis of anti-NMDAR encephalitis. The modified Rankin Scale (mRS) scores were used to divide the anti-NMDAR-encephalitis into two groups (poor prognosis vs. good prognosis). Chi-square test and logistic regression were used to analyze factors associated with prognosis.

RESULTS

Here, 78 patients were included. The most common clinical characteristics are cognitive dysfunction (86.0%) and thought disorder (86.0%). Cognitive dysfunction, thought disorder, and seizures tended to appear soon after prodrome symptoms. Logistics analysis results showed that cognitive dysfunction (OR = 4.48, 95% CI = 1.09-18.47), the score of (GCS ≤ 8) (OR = 4.52, 95% CI = 1.18-17.32), positive antibodies in serum (OR = 4.89, 95% CI = 1.19-20.13) and delay immunotherapy (OR = 4.76, 95% CI = 1.79-12.60) were risk factors of poor clinical outcomes.

CONCLUSIONS

There are two peaks in the development of autoimmune encephalitis (AE). The first peak is cognitive dysfunction, and the second peak is autonomic dysfunction. Cognitive dysfunction and GCS score ≤8 at admission, antibodies positive in serum, and delay immunotherapy were risk factors for a poor prognosis at discharge.

Analysis of the Effect of Incentive Nursing Intervention in Children with Severe Viral Encephalitis and Myocarditis during Rehabilitation Based on Diffusion Weighted MRI

Background

Severe viral encephalitis in children causes a viral infection that damages their central nervous system. This situation arises the mental abnormalities, sudden rise in body temperature, disturbance of consciousness, and so forth in children, which can be life-threatening.

Objective

This work aimed at exploring the effect of diffusion weighted MRI on children with severe viral encephalitis and myocarditis.

Methods

This work presents a diffusion weighted MRI scanning method that involves scanning through a serial imaging device, axial scanning, and sagittal and coronal scanning. 60 children with severe viral encephalitis and myocarditis who admitted to Brain Hospital of Hunan Province from April 2017 to May 2020 were deemed as research subjects. All the children underwent CT and MRI examination, blood routine examination, and cerebrospinal fluid examination after admission. This work uses the random number table method to classify the subjects into control group and observation group, each consisting of 30 cases. Children in the control group were provided with the routine nursing intervention, whereas children in the observation group were subjected to incentive nursing intervention. The baseline data, ECG monitoring indicators, body abnormalities, and clinical symptom relief time of the two groups of children were compared and the results of diffusion weighted MRI scans were analyzed and the ADC values were counted.

Results

The two groups of children were compared on the basis of baseline data, and the variation was not statistically substantial (P > 0.05). The cases of children in the control group had higher heart rate and respiration, and physical dysfunction, language dysfunction, unconsciousness, and nervous dysfunction were more than those in the observation group. However, the cases of blood oxygen saturation were less than those of the observation group. After nursing intervention done for the control group, remission time of clinical symptoms such as convulsion, physical dysfunction, unconsciousness, and nerve dysfunction was longer relative to the observation group (all P < 0.05 are considered).

Conclusion

The diffusion weighted MRI had diagnostic significance for severe viral encephalitis and myocarditis. For children with severe viral encephalitis and myocarditis, clinical incentive nursing intervention was particularly imperative. It can not only help children to relieve symptoms and control the deterioration of the disease in a short time but also help improve the quality of life of the children and the confidence of family members to cope with the disease.

Recurrent anti-NMDAR encephalitis during pregnancy combined with two antibodies positive

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune synaptic encephalitis likely mediated by neuronal surface antibody. Clinically, it is characterized by a variety of neurological and psychiatric symptoms, predominantly affecting young women. Recurrent anti-NMDAR cases combined with double-antibody positive during pregnancy have not been reported. We report a 19-year-old pregnant woman with recurrent anti-NMDAR encephalitis and double-antibody positive. Through our case report and a review of the literature, we hope to heighten an awareness of anti-NMDAR encephalitis, particularly in a pregnant setting.

A Case of Anti-NMDA Receptor Encephalitis During Dinutuximab Therapy for Neuroblastoma

Dinutuximab is a monoclonal antibody administered to patients with high-risk neuroblastoma, usually after an autologous stem cell transplant. Dinutuximab is associated with immune mediated and neurologic toxicities, but fatal adverse events are rare. A case is presented of high-risk neuroblastoma with development of encephalopathy shortly after the first course of dinutuximab. The patient had extensive evaluation for etiology of the symptoms and received aggressive interventions, but ultimately expired. Postmortem diagnosis of anti-N-methyl D-aspartate receptor encephalitis, an autoimmune phenomenon often triggered by infection or malignancy, was made. The potential association of autoimmune encephalitis with dinutuximab and with previous autologous transplant is discussed.

Clinical Characteristics and Prognostic Factors of Children With Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Objective: Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is the most common autoimmune encephalitis in pediatric patients. The study aimed to investigate the clinical characteristics and prognostic factors of anti-NMDA receptor encephalitis in children in South China. Methods: This was a retrospective study of children diagnosed with anti-NMDA receptor encephalitis between 01/2014 and 12/2017 at Hunan Children's Hospital. Laboratory, brain magnetic resonance imaging (MRI), and electroencephalography data were collected. The short-term (6-month) outcomes were assessed using the Liverpool score by the same pediatric neurologist. The children were divided into good (scores 4-5) and poor (score <3) clinical outcomes. Results: Among the 51 patients, 21 (41.2%) were male. The most common clinical symptoms were dyskinesia (88.2%), personality change (84.3%), seizure (82.4%), and cognitive disorder (31.4%). Two were transferred to another hospital, 45 (91.8%) received intravenous immunoglobulins, 41 (83.7%) received methylprednisolone, and 8 (16.3%) received plasma exchange. Eight (16.3%) received rituximab for second-line treatment, six after intravenous immunoglobulin and methylprednisolone treatment, and two after plasma exchange therapy failed. Seven were lost to follow-up. The short-term outcome was good in 23 patients. Cognitive disorder [odds ratio (OR): 23.97, 95% confidence interval (CI): 1.12-513.30, P = 0.042) and abnormal brain MRI (OR: 14.29, 95% CI: 1.36-150.10, P = 0.027] were independently associated with a poor short-term outcome after adjustment for age, GCS, and rituximab use. Conclusions: MRI abnormalities and cognitive disorders are independently associated with poor short-term outcomes in children with anti-NMDA receptor encephalitis. The use of rituximab is not associated with the 6-month outcomes.

[Anti-NMDAR encephalitis associated with relapsing optic neuritis]

Autoimmune encephalitis with antibodies to NMDA receptors (anti-NMDAR encephalitis), is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.

EEG Findings and Releases From Hospital for Patients With Anti-NMDA Receptor Encephalitis

PURPOSE

Anti-N-methyl-D-aspartate receptor encephalitis is produced by an autoimmune reaction against macromolecular structures that form ionotropic receptors for glutamic acid NR2A and NR2B subunits. Other important findings are the multiple clinical and paraclinical manifestations, among which the EEG stands out. We characterized EEG patterns and their association with functional disability and hospitalization time in patients with anti-N-methyl-D-aspartate receptor encephalitis admitted in our center.

METHODS

We performed a retrospective cohort study that included patients with anti-N-methyl-D-aspartate receptor encephalitis. We recorded the clinical and sociodemographic characteristics and initial scalp EEG data. Functional disability was evaluated at admission and follow-up using the modified Rankin scale.

RESULTS

Forty-five patients aged 15 to 80 years were included. An abnormal EEG was reported in 92.5% of patients. We identified six EEG patterns. The mean hospitalization time was 3.2 (±2.4) months. The higher modified Rankin scale at admission and the absence of parietal or temporal epileptiform activity were associated with more prolonged hospitalization, hazard ratio of 0.338 for each modified Rankin scale level (95% confidence interval 0.174-0.658, P = 0.001), 14.5, P = 0.017, and hazard ratio of 5.6, P = 0.009, respectively.

CONCLUSIONS

EEGs are frequently abnormal in patients with anti-N-methyl-D-aspartate receptor encephalitis. The lower modified Rankin scale at admission and the absence of some focal epileptiform activity may be associated with shorter hospitalizations.

Clinical characteristics and long-term prognosis of relapsing anti-N-methyl-D-aspartate receptor encephalitis: a retrospective, multicenter, self-controlled study

Objective

To analyze the clinical profile and long-term prognosis of relapsing anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis.

Method

This is a retrospective, multicenter, self-controlled study of 10 patients with relapsing anti-NMDAR encephalitis. Relapse was defined as new psychiatric or neurologic syndrome unexplainable by other causes that improved after immunotherapy.

Results

The main symptoms at first onset and relapse included psychiatric symptoms, cognitive impairment, speech dysfunction, seizures, consciousness disturbance, movement disorders, central hypoventilation, and autonomic dysfunction. There were significantly fewer seizures and consciousness disturbances at relapse. At the first onset, the antibody positivity rate was significantly higher in the cerebrospinal fluid (CSF) than in the serum, and abnormal electroencephalograms results were noted in all patients. The relapse rate was 12.2%. After first-onset discharge, the duration of medication intake was 3.10 ± 2.69 months; the relapse time was 18.3 ± 16.5 months. The Modified Rankin Scale (MRS) score at relapse was significantly lower than that at the first onset. The MRS scores at relapse and first onset after immunotherapy were significantly lower than those before immunotherapy. At follow-up, the average duration of antiepileptic drug (AED) intake was < 1 year; the relapse rate was low.

Conclusions

Patients have fewer symptoms and better quality of life at relapse than at the first onset. Active immunotherapy can significantly improve the quality of life during first onset and relapse. Encephalitis antibody testing in the CSF is preferred at first onset and relapse. Increasing antibody titers suggest clinical relapse. Prematurely stopping immunotherapy may lead to relapse, but prolonged AED intake is unnecessary.

Anti-N-methyl-D-aspartate-receptor antibody encephalitis combined with syphilis: A case report

BACKGROUND

Anti-N-methyl-D-aspartate-receptor (NMDAR) encephalitis is a common type of autoimmune encephalitis characterized by complex clinical signs and variable imaging manifestations. The pathogenesis of the disease is unclear. Syphilis is an infectious disease caused by Treponema pallidum that can invade the nervous and immune systems and cause systemic symptoms. There are few reports of anti-NMDAR encephalitis with syphilis, and the association between them is unknown; both diseases are related to immune system damage. We report a case of anti-NMDAR encephalitis with syphilis.

CASE SUMMARY

A 32-year-old man was admitted to our hospital with complaints of cognitive decline, diplopia, and walking instability during the previous 6 mo. He developed dysarthria, difficulty swallowing, and involuntary shaking of his head, neck, and limbs during the month prior to presentation. Cranial magnetic resonance imaging showed symmetrical abnormal signals in the pons, midbrain, and bilateral basal ganglia, and inflammatory demyelination was considered. The diagnosis of syphilis was confirmed based on the syphilis diagnosis test and the syphilis rapid test. He was given anti-syphilis treatment, but the above symptoms gradually worsened. Anti-NMDAR antibody was positive in cerebrospinal fluid but was negative in serum. Due to the cerebrospinal fluid findings, anti-NMDAR encephalitis was a consideration. According to the patient’s weight, he was treated with intravenous methylprednisolone 1 g QD for 5 d, with the dose gradually decreased for 6 mo, and immunoglobulin 25 g QD for 5 d; his symptoms improved after treatment.

CONCLUSION

This case shows that anti-NMDAR encephalitis may be combined with syphilis, which should be recognized to avoid misdiagnosis and treatment delay.

Neurocritical care for Anti-NMDA receptor encephalitis

In this review, we summarize the clinical presentations of the acute stage of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis and the neurocritical care strategy in intensive care units. Anti-NMDA receptor encephalitis has characteristic clinical features and is predominantly seen in young adults and children. Most patients have five stages of clinical presentation, including a prodromal phase, psychotic and/or seizure phase, unresponsive and/or catatonic phase, hyperkinetic phase, and gradual recovery phase. The clinical course usually begins with viral infection-like symptoms that last for up to 2 weeks (prodromal phase), followed by the rapid development of schizophrenia-like psychiatric symptoms and seizures (psychotic and seizure phase). Patients may have a decreased level of consciousness with central hypoventilation, frequently requiring mechanical ventilation. In the subsequent hyperkinetic phase, patients present with orofacial-limb dyskinesia and autonomic instability. Children with significant neurological symptoms of anti-NMDA receptor encephalitis should initially be managed in a pediatric intensive care unit. The acute critical presentations are, refractory seizures, autonomic dysfunction, hypoventilation, cardiac arrhythmia, and hyperkinetic crisis. Symptom-guided therapies and critical care are necessary in the acute stage to improve the prognosis.

[Anti-NMDAR encephalitis associated with relapsing optic neuritis: a case report and differential diagnosis]

Autoimmune encephalitis with antibodies to NMDA receptors, or anti-NMDAR encephalitis, is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article presents the literature review and describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis, which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.

Anti-N-methyl-D-aspartate receptor encephalitis with accompanying ovarian teratoma in female patients from East China: Clinical features, treatment, and prognostic outcomes

PURPOSE

The association between anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR encephalitis) and teratoma is formally recognized. This study compared the clinical features, treatments and outcomes between female patients with or without accompanying teratomas and determined the potential influences of coexisting teratomas.

METHOD

Fifty-six female patients diagnosed with anti-NMDAR encephalitis were enrolled in two major tertiary hospitals in East China from January 2013 through March 2018 and were grouped as patients with or without teratoma. The clinical features were reviewed, and follow-up studies were performed. Comparisons were made between the two groups.

RESULTS

Patients with teratoma reported fewer viral prodromes (p = 0.0085) and stronger positive intensity of anti-NMDAR antibodies in cerebrospinal fluid (CSF) (p = 0.0368), while nontumor patients tended to demonstrate lymphocytic pleocytosis in CSF (p = 0.0306). Seizure types varied between individuals, with complex partial seizures more common in teratoma patients (p = 0.0105). Nontumor patients frequently required combinations of first-line and second-line immunotherapy (p = 0.0014), which may be attributed to higher mRS scores at admission (p = 0.0300). Also, they had higher mean mRS scores since the 12-month follow-up and greater probability of relapse than did patients with teratomas (p = 0.0286).

CONCLUSIONS

Symptomatology and auxiliary findings indicate that ovarian teratoma may be the immunologic trigger for anti-NMDAR encephalitis patients, while viral infection is likely to play a major part in pathogenesis for those without any detectable tumor. Overall, anti-NMDAR encephalitis patients with teratomas present with milder neurological symptoms and have better long-term outcomes after tumor removal.

Anti-N-methyl-D-aspartate receptor encephalitis: A review of pathogenic mechanisms, treatment, prognosis

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatable autoimmune disorder characterized by prominent neuropsychiatric symptoms that predominantly affects children and young adults. In this review, we discuss the pathogenic mechanisms and immunologic triggers of anti-NMDAR encephalitis, and provide an overview of treatment and prognosis of this disorder, with specific focus on the management of common symptoms, complications, and patients during pregnancy. Most patients respond well to first-line treatment and surgical resection of tumors. When first-line immunotherapy fails, second-line immunotherapy can often improve outcomes. In addition, treatment with immunomodulators and tumor resection are effective treatment strategies for pregnant patients. Benzodiazepines are the preferred treatment for patients with catatonia, and electroconvulsive therapy (ECT) may be considered when pharmacological treatment is ineffective. Age, antibody titer, cerebellar atrophy, levels of biomarkers such as C-X-C motif chemokine 13 (CXCL13), cell-free mitochondrial (mt)DNA in cerebral serum fluid (CSF), and timing from symptom onset to treatment are the main prognostic factors. Patients without tumors or those who receive insufficient immunotherapy during the first episode are more likely to relapse.

Nursing care in anti-N-methyl-D-aspartate receptor encephalitis: A case series

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a paraneoplastic limbic encephalitis, recently identified.To summarize our experience in the nursing care of patients with anti-NMDAR encephalitis managed with surgery and pharmacotherapy.This study included 45 patients treated between July 2015 and November 2016. Laparoscopic oophorocystectomy was performed in 11 female patients with teratomas. Eleven patients required tracheal intubation or tracheotomy and ventilation.The patients were hospitalized for an average of 25.2 days. The mental and neurological symptoms were significantly relieved 23.6 ± 4.8 days after surgery or immunotherapy. Near-normal function was restored in 11 patients, while 34 patients had varying degrees of dysfunction at discharge. After follow-up of 1 to 18 months, 24 patients were found to have permanent impairments.Appropriate symptomatic nursing care is required to ensure the safety of patients with anti-NMDAR encephalitis.

Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis

OBJECTIVES

Anti-N-methyl-D-aspartate receptor encephalitis is considered an immune-mediated form of encephalitis with paraneoplastic and nonparaneoplastic forms. Delay in recognition is common and patients typically present to the ICU without a diagnosis or with complications following a delayed diagnosis. The aim of this review is to provide a focused overview for the ICU clinician regarding presentation, diagnosis, and critical care management.

DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION

PubMed database search with manual review of articles involving anti-N-methyl-D-aspartate receptor encephalitis.

DATA SYNTHESIS

Anti-N-methyl-D-aspartate receptor encephalitis is increasingly encountered in the ICU. The cascade of events initiating anti-N-methyl-D-aspartate receptor antibody formation may involve an infectious trigger particularly in the setting of teratoma. Following a prodrome, most patients develop psychiatric symptoms followed by movement disorder. Classical, psychiatric, and catatonic phenotypes may be distinguished based on the presence and severity of symptoms. Early immunotherapy and low initial cerebrospinal fluid inflammation are independent predictors of positive outcomes in ICU patients. Concomitant organ failure, status epilepticus, and the identification of a tumor did not influence outcome in critically ill patients. Supportive care in the ICU includes management of various manifestations of dyskinesia, status epilepticus, autonomic disorders, and the need for general sedation. Common treatment strategies and limitations are discussed including the emerging role of bortezomib.

CONCLUSIONS

Intensivists should be familiar with the presentation and management of anti-N-methyl-D-aspartate receptor encephalitis. Early diagnosis and immediate implementation of steroids, immunoglobulins, and/or plasmapheresis and immune therapy are associated with a good neurologic outcome although response may be delayed. The selection and timing of second-line immune therapy requires further study.

Anti-NMDA Receptor Encephalitis Presenting with Status Epilepticus: Brucellosis as a Possible Triggering Factor: A Case Report

Brucellosis is a common zoonotic infection caused by bacterial genus Brucella, a Gram-negative bacterium, and continued to be a health problem in endemic areas. Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an autoimmune disease which can lead to status epilepticus. A 19-year-old male patient was referred to our hospital with status epilepticus. The diagnosis of brucellosis was confirmed about 2 weeks before. The brain magnetic resonance imaging was normal. Lumbar puncture was performed, and cerebral spinal fluid (CSF) was in normal limits. The patient was treated with antiepileptic, anti-brucellosis agents. Two weeks after discharge, the patient readmitted to hospital with status epilepticus again. Extensive workup was negative except that NMDAR antibodies were detected in serum and CSF. The diagnosis of anti-NMDAR encephalitis was established. Brucellosis as a triggering factor for NMDAR encephalitis should be considered.

Elevated Serum and Cerebrospinal Fluid CD138 in Patients With Anti-N-Methyl-d-Aspartate Receptor Encephalitis

Background

CD138 (also known as syndecan-1) is an important component of endothelial cell glycocalyx, and it is reportedly involved in negative regulation of various inflammatory processes. The clinical implications of circulating and cerebrospinal fluid (CSF) soluble CD138 (sCD138) in patients with Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis remain unclear.

Objective

The aim of the current study was to investigate associations between serum and CSF sCD138 levels in anti-NMDAR encephalitis patients.

Methods

The participants enrolled in the study included 27 with anti-NMDAR encephalitis, 11 with viral meningoencephalitis, and 22 controls. At acute stage and 3 to 6-month follow-up time-points, sCD138, tumor necrosis factor-α, matrix metalloproteinase-2, and matrix metalloproteinase-9 in serum and CSF were measured in all participants via enzyme-linked immunosorbent assays.

Results

Serum and CSF levels of sCD138 were significantly increased in patients with anti-NMDAR encephalitis. Furthermore, after 3–6 months of follow-up CSF sCD138 levels were significantly decreased in anti-NMDAR encephalitis patients. Changes in sCD138 levels were significantly associated with amelioration of modified Rankin Scale scores in patients with anti-NMDAR encephalitis.

Conclusion

In anti-NMDAR encephalitis patients, high circulating, and CSF sCD138 is associated with inflammation and poor clinical prognosis. The present study suggests that sCD138 may be an informative biomarker of inflammation in anti-NMDAR encephalitis.

N-Methyl-d-aspartate Receptor Antibody Encephalitis: A Concise Review of the Disorder, Diagnosis, and Management

Anti-NMDA ( N-methyl-d-aspartate) receptor (anti-NMDAR) encephalitis is one of the most common paraneoplastic encephalitides. It occurs in both sexes, across all age ranges, and may occur in the presence or absence of an associated tumor. Its pathogenesis and clinical presentation relate to the presence of IgG1 or IgG3 antibodies targeting the NR1 subunit of the NMDA receptor, leading to a disinhibition of neuronal excitatory pathways. Initial clinical manifestations may be nonspecific, resembling a viral-like illness; however, with disease progression, symptoms can become quite severe, including prominent psychiatric features, cognitive problems, motor dysfunction, and autonomic instability. Anti-NMDAR encephalitis may even result in death in severe untreated cases. Diagnosis can be challenging, given that initial laboratory and radiographic results are typically nonspecific. The majority of patients respond to first or second-line treatments, although therapeutic options remain limited, usually consisting of tumor removal (if there is confirmation of an underlying malignancy) in conjunction with prompt initiation of immunosuppressive medications along with intravenous immunoglobulins and/or plasma exchange. Although the clinical presentation of anti-NMDAR encephalitis overlaps with several other more common neurological and psychiatric disorders, early diagnosis and treatment is essential for a positive prognosis. Here, we concisely review the pathogenesis, diagnosis, and clinical management of this disease.

Autoantibodies and Psychosis

Research into antibody-mediated disease, in response to immune dysfunction or to tumour development, has rapidly expanded in recent years. Antibodies binding to neuroreceptors can cause psychiatric features, including psychosis, in a minority of patients as well as neurological features. The responsiveness of some of these cases to immunotherapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic diseases. The purpose of this chapter is to review autoantibodies that are most likely to be relevant for patients with psychotic symptoms. Herein, we describe receptor structure and mechanism of action, clinical and psychiatric features for the growing number of neuronal surface antibodies, including those to the N-methyl-D-aspartate (NMDA) receptor. The identification of a subgroup of patients with psychiatric features having antibody-mediated disease highlights the importance of considering the diagnosis, particularly in those patients presenting with a first episode of psychosis.

Analysis and discussion of the rare complication of autoimmune encephalitis: Two case reports

RATIONALE

Autoimmune encephalitis related to many antibodies against neuronal cell surface or synaptic proteins, it is increasingly recognized as the cause of a variety of neuropsychiatric syndromes.

PATIENT CONCERNS

The two pediatric cases were about autoimmune encephalitis with rare complication. One patient was a 11-year-old girl and was diagnosed with Voltage-Gated Potassium Channel complex (VGKC) antibody-mediated encephalitis with rhabdomyolysis; the other was also a 11-year-old girl and was diagnosed with anti- N-methyl-D-aspartate receptor (NMDAR) encephalitis.

DIAGNOSES

Both patients were diagnosed as autoimmune encephalitis with rare complication.

INTERVENTIONS

Intravenous methylprednisolone, oral prednisone and intravenous immunoglobulin was administered to both patients.

OUTCOMES

One patient was discharged after a half month's hospitalization; the other was finally with intestinal function failure, gradually developed multiple organ failure, and eventually died.

LESSONS

The pathogenic mechanism of autoimmune encephalitis associated with autoimmune disease is not fully understood, but may be related to a common immune pathological mechanism with variance in susceptibility caused by genetic or environmental factors.

Brain MRI Characteristics of Patients with Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Their Associations with 2-Year Clinical Outcome

BACKGROUND AND PURPOSE

Anti-N-methyl-D-aspertate receptor encephalitis is an autoimmune-mediated disease without specific brain MRI features. Our aim was to investigate the brain MR imaging characteristics of anti-N-methyl-D-aspartate receptor encephalitis and their associations with clinical outcome at a 2-year follow-up.

MATERIALS AND METHODS

We enrolled 53 patients with anti-N-methyl-D-aspartate receptor encephalitis and performed 2-year follow-up. Brain MRIs were acquired for all patients at the onset phase. The brain MR imaging manifestations were classified into 4 types: type 1: normal MR imaging findings; type 2: only hippocampal lesions; type 3: lesions not involving the hippocampus; and type 4: lesions in both the hippocampus and other brain areas. The modified Rankin Scale score at 2-year follow-up was assessed, and the association between the mRS and onset brain MR imaging characteristics was evaluated.

RESULTS

Twenty-eight (28/53, 53%) patients had normal MR imaging findings (type 1), and the others (25/53, 47%) had abnormal MRI findings: type 2: 7 patients (13%); type 3: seven patients (13%); and type 4: eleven patients (21%). Normal brain MRI findings were more common in female patients (P = .02). Psychiatric and behavioral abnormalities were more common in adults (P = .015), and autonomic symptoms (P = .025) were more common in pediatric patients. The presence of hippocampal lesions (P = .008, OR = 9.584; 95% CI, 1.803-50.931) and relapse (P = .043, OR = 0.111; 95% CI, 0.013-0.930) was associated with poor outcome.

CONCLUSIONS

Normal brain MRI findings were observed in half of the patients. Lesions in the hippocampus were the most common MR imaging abnormal finding. The presence of hippocampal lesions is the main MR imaging predictor for poor prognosis in patients with anti-N-methyl-D-aspartate receptor encephalitis.

The efficacy of adrenocorticotropic hormone in a girl with anti-N-methyl-D-aspartate receptor encephalitis

BACKGROUND

Immunomodulatory therapy has shown some therapeutic benefits in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. In this report, we describe the use of adrenocorticotropic hormone (ACTH) immunotherapy with good outcome in a patient with anti-NMDAR encephalitis.

SUBJECT AND METHODS

A 4-year-old girl developed convulsions in her right arm and leg without impaired consciousness. These convulsions occurred frequently in clusters of 10-20 events of 10-20 s duration. She was admitted to our hospital on the 6th day following her initial series of convulsions. Flaccid paralysis of the right hand and leg was also found. Interictal electroencephalography showed high-amplitude slow waves. No abnormal findings were shown on MRI. ^99mTc-ECD brain SPECT on the 14th day showed hyperperfusion in the left hemisphere, including the left basal ganglia. The convulsions ceased following the oral administration of valproic acid on the 10th day; however, paralysis associated with choreic dyskinesia of the right arm and leg remained. ACTH immunotherapy was then performed on the 15th day. We identified the presence of N-methyl-D-aspartate receptor antibody in CSF samples taken on the 6th day. After ACTH therapy, the patient fully recovered from the paralysis associated with choreic dyskinesia of the right arm and leg. She has not had a relapse and has not required medication for over a year.

CONCLUSION

ACTH immunotherapy may be a useful treatment option for patients with anti-NMDAR encephalitis, although further evaluation is required.

An Infant Born to a Mother With Anti-N-Methyl-d-Aspartate Receptor Encephalitis

BACKGROUND

Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is an autoimmune disorder that often affects women of childbearing age, and maternal-fetal transfer of anti-NMDAR antibodies during pregnancy has been documented in both symptomatic and asymptomatic women. The effects of these antibodies on the fetus, however, are incompletely understood.

PATIENT DESCRIPTION

This term infant exhibited depressed respiratory effort, poor feeding, and abnormal movements after birth. Magnetic resonance imaging revealed diffuse cerebral edema with ischemic and hemorrhagic injury. Her mother had experienced anti-NMDAR encephalitis secondary to an ovarian teratoma 18 months earlier. The baby's serum NMDAR antibody titer was elevated at 1:320. Intravenous immunoglobulin did not result in clinical improvement, and care was withdrawn on day of life 20. Her mother had an elevated serum NMDAR antibodies (1:80), positive CSF antibody titers, and a new ovarian teratoma.

CONCLUSION

Routine testing of NMDAR antibodies in pregnant women with a previous history of anti-NMDAR encephalitis may be warranted. Infants born to these mothers should be closely monitored throughout pregnancy and after birth.

Adolescent with acute psychosis due to anti-N-methyl-D-aspartate receptor encephalitis: successful recovery

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively new autoimmune disorder of the central nervous system. We report the first case of anti-NMDAR autoimmune encephalitis combined with anti-voltage-gated potassium channel (anti-VGKC) antibodies in Lithuania in a 16-year-old girl. The patient was admitted to psychiatry unit because of an acute psychotic episode. She was unsuccessfully treated with antipsychotics, and electroconvulsive therapy was initiated because of her rapidly deteriorating condition. Electroconvulsive therapy improved the patient’s condition even before the initiation of immunomodulatory therapy. The abrupt onset, atypical and severe course of psychosis, poor response to antipsychotic treatment, and signs of flu-like prodromal period led to the search of non-psychiatric causes. Although with considerable delay, she was screened for an autoimmune encephalitis. Positive anti-NMDA receptor antibodies were found in the cerebrospinal fluid, but not in serum. In addition, serum was found positive for antinuclear antibodies and anti-VGKC antibodies but negative for CASPR2 and LGI1 antibodies. The girl was treated with intravenous immunoglobulin and methylprednisolone with satisfactory response, although infrequent orofacial movements, emotional lability, and learning deficits remained upon discharge. The reported case suggests that multiple antibodies could be present, and that electroconvulsive therapy may have a role in symptomatic treatment of autoimmune encephalitis.