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Legouy C, Cervantes A, Sonneville R, Thakur KT. Autoimmune and inflammatory neurological disorders in the intensive care unit. Curr Opin Crit Care 2024; 30:142-150. [PMID: 38441114 DOI: 10.1097/mcc.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the diagnostic approach to autoimmune encephalitis (AE) in the intensive care unit (ICU) and provides practical guidance on therapeutic management. RECENT FINDINGS Autoimmune encephalitis represents a group of immune-mediated brain diseases associated with antibodies that are pathogenic against central nervous system proteins. Recent findings suggests that the diagnosis of AE requires a multidisciplinary approach including appropriate recognition of common clinical syndromes, brain imaging and electroencephalography to confirm focal pathology, and cerebrospinal fluid and serum tests to rule out common brain infections, and to detect autoantibodies. ICU admission may be necessary at AE onset because of altered mental status, refractory seizures, and/or dysautonomia. Early management in ICU includes prompt initiation of immunotherapy, detection and treatment of seizures, and supportive care with neuromonitoring. In parallel, screening for neoplasm should be systematically performed. Despite severe presentation, epidemiological studies suggest that functional recovery is likely under appropriate therapy, even after prolonged ICU stays. CONCLUSION AE and related disorders are increasingly recognized in the ICU population. Critical care physicians should be aware of these conditions and consider them early in the differential diagnosis of patients presenting with unexplained encephalopathy. A multidisciplinary approach is mandatory for diagnosis, ICU management, specific therapy, and prognostication.
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Affiliation(s)
- Camille Legouy
- GHU Paris Psychiatrie & Neurosciences, Department of Intensive Care Medicine, Paris, France
| | - Anna Cervantes
- Divisions of Neurocritical Care and Neuroinfectious Disease, Boston Medical Center, Boston, Massachusetts, USA
| | - Romain Sonneville
- Université Paris Cité, IAME, INSERM UMR1137
- AP-HP, Hôpital Bichat - Claude Bernard, Department of Intensive Care Medicine, Paris, France
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
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Gilligan M, McGuigan C, McKeon A. Autoimmune central nervous system disorders: Antibody testing and its clinical utility. Clin Biochem 2024; 126:110746. [PMID: 38462203 PMCID: PMC11016295 DOI: 10.1016/j.clinbiochem.2024.110746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
A rapidly expanding repertoire of neural antibody biomarkers exists for autoimmune central nervous system (CNS) disorders. Following clinical recognition of an autoimmune CNS disorder, the detection of a neural antibody facilitates diagnosis and informs prognosis and management. This review considers the phenotypes, diagnostic assay methodologies, and clinical utility of neural antibodies in autoimmune CNS disorders. Autoimmune CNS disorders may present with a diverse range of clinical features. Clinical phenotype should inform the neural antibodies selected for testing via the use of phenotype-specific panels. Both serum and cerebrospinal fluid (CSF) are preferred in the vast majority of cases but for some analytes either CSF (e.g. N-methyl-D-aspartate receptor [NMDA-R] IgG) or serum (e.g. aquaporin-4 [AQP4] IgG) specimens may be preferred. Screening using 2 methods is recommended for most analytes, particularly paraneoplastic antibodies. We utilize murine tissue-based indirect immunofluorescence assay (TIFA) with subsequent confirmatory protein-specific testing. The cellular location of the target antigen informs choice of confirmatory diagnostic assay (e.g. blot for intracellular antigens such as Hu; cell-based assay for cell surface targets such as leucine-rich glioma inactivated 1 [LGI1]). Titers of positive results have limited diagnostic utility with the exception of glutamic acid decarboxylase (GAD) 65 IgG autoimmunity, which is associated with neurological disease at higher values. While novel antibodies are typically discovered using established techniques such as TIFA and immunoprecipitation-mass spectrometry, more recent high-throughput molecular technologies (such as protein microarray and phage-display immunoprecipitation sequencing) may expedite the process of antibody discovery. Individual neural antibodies inform the clinician regarding the clinical associations, oncological risk stratification and tumor histology, the likely prognosis, and immunotherapy choice. In the era of neural antibody biomarkers for autoimmune CNS disorders, access to appropriate laboratory assays for neural antibodies is of critical importance in the diagnosis and management of these disorders.
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Affiliation(s)
- Michael Gilligan
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Yang B, Yu N. Glucocorticoid-dependent multiple sclerosis overlapping anti-NMDA receptor encephalitis: a case report and literature review update. Neurol Sci 2024; 45:83-92. [PMID: 37721572 PMCID: PMC10761549 DOI: 10.1007/s10072-023-07034-x] [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: 06/21/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Previous studies suggest a relationship between central nervous system inflammatory demyelinating diseases and anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. Also, the overlap between anti-NMDAR encephalitis and multiple sclerosis (MS) has been reported. However, the pathogenesis and clinical characteristics are still obscure. CASE PRESENTATION A 33-year-old woman presented with diplopia and sensory ataxia at the onset. The cerebrospinal fluid (CSF) anti-NMDAR antibodies were positive (1:3.2), and nuclear magnetic resonance imaging (MRI) showed bilateral centrum ovale and lateral ventricle demyelinating lesions. Therefore, she was diagnosed with anti-NMDAR encephalitis. After administering intravenous immunoglobulin and oral prednisone, her lesions disappeared, and symptoms were relieved. The condition was maintained with a low dose of prednisone, but her lesions reappeared on MRI. Consequently, immunomodulatory therapy of mycophenolate mofetil was initiated. However, she developed dysarthria and right limb ataxia after 10 months with a positive CSF anti-NMDAR antibody (1:1) and positive oligoclonal band. The MRI showed symmetrical multiple demyelinating lesions. Considering the MS diagnosis, her neurological dysfunction again improved significantly after intravenous methylprednisolone. Unfortunately, her symptoms aggravated for the second time when teriflunomide was started. Finally, her condition was controlled again with oral prednisone. CONCLUSIONS Consistent with previous cases of overlapping anti-NMDAR encephalitis and MS, patients often show atypical symptoms on MRIs and immunological tests. The overlap cannot be arbitrarily treated because of the recurrence of previous diseases. Long-term follow-up, dynamic antibody monitoring, and MRI examination are crucial for these patients. The special dependency of the patient on glucocorticoids in this study has been rarely reported, which may guide the treatment of insensitivity to disease-modifying therapy in recurrent overlapping anti-NMDAR encephalitis and MS.
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Affiliation(s)
- Bo Yang
- Department of Center for Psychosomatic Medicine, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Nengwei Yu
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section of First Loop, Qingyang District, Chengdu City, Sichuan Province, China.
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Monson N, Smith C, Greenberg H, Plumb P, Guzman A, Tse K, Chen D, Zhang W, Morgan M, Speed H, Powell C, Batra S, Cowell L, Christley S, Vernino S, Blackburn K, Greenberg B. VH2+ Antigen-Experienced B Cells in the Cerebrospinal Fluid Are Expanded and Enriched in Pediatric Anti-NMDA Receptor Encephalitis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 211:1332-1339. [PMID: 37712756 PMCID: PMC10593502 DOI: 10.4049/jimmunol.2300156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
Pediatric and adult autoimmune encephalitis (AE) are often associated with Abs to the NR1 subunit of the N-methyl-d-aspartate (NMDA) receptor (NMDAR). Very little is known regarding the cerebrospinal fluid humoral immune profile and Ab genetics associated with pediatric anti-NMDAR-AE. Using a combination of cellular, molecular, and immunogenetics tools, we collected cerebrospinal fluid from pediatric subjects and generated 1) flow cytometry data to calculate the frequency of B cell subtypes in the cerebrospinal fluid of pediatric subjects with anti-NMDAR-AE and controls, 2) a panel of recombinant human Abs from a pediatric case of anti-NMDAR-AE that was refractory to treatment, and 3) a detailed analysis of the Ab genes that bound the NR1 subunit of the NMDAR. Ag-experienced B cells including memory cells, plasmablasts, and Ab-secreting cells were expanded in the pediatric anti-NMDAR-AE cohort, but not in the controls. These Ag-experienced B cells in the cerebrospinal fluid of a pediatric case of NMDAR-AE that was refractory to treatment had expanded use of variable H chain family 2 (VH2) genes with high somatic hypermutation that all bound to the NR1 subunit of the NMDAR. A CDR3 motif was identified in this refractory case that likely drove early stage activation and expansion of naive B cells to Ab-secreting cells, facilitating autoimmunity associated with pediatric anti-NMDAR-AE through the production of Abs that bind NR1. These features of humoral immune responses in the cerebrospinal fluid of pediatric anti-NMDAR-AE patients may be relevant for clinical diagnosis and treatment.
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Affiliation(s)
- Nancy Monson
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX
| | - Chad Smith
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Hannah Greenberg
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Patricia Plumb
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Alyssa Guzman
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Key Tse
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Ding Chen
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Wei Zhang
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Miles Morgan
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Haley Speed
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Craig Powell
- Department of Neurobiology, Civitan International Research Center, University of Alabama Marnix E. Heersink School of Medicine, Birmingham, AL
| | - Sushobhna Batra
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Lindsay Cowell
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Scott Christley
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Steve Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Kyle Blackburn
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
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Kirschstein T, Köhling R. Functional changes in neuronal circuits due to antibody-driven autoimmune response. Neurobiol Dis 2023:106221. [PMID: 37414365 DOI: 10.1016/j.nbd.2023.106221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023] Open
Abstract
Autoimmune-mediated encephalitis syndromes are increasingly being recognized as important clinical entities. They need to be thought of as differential diagnosis in any patient presenting with fast-onset psychosis or psychiatric problems, memory deficits or other cognitive problems, including aphasias, as well as seizures or motor automatisms, but also rigidity, paresis, ataxia or dystonic / parkinsonian symptoms. Diagnosis including imaging and CSF search for antibodies needs to be fast, as progression of these inflammatory processes is often causing scarring of brain tissue, with hypergliosis and atrophy. As these symptoms show, the autoantibodies present in these cases appear to act within the CNS. Several of such antibodies have by now been identified such as IgG directed against NMDA-receptors, AMPA receptors, GABAA and GABAB receptors, and voltage gated potassium channels and proteins of the potassium channel complex (i.e. LGI1 and CASPR2). These are neuropil / surface antigens where antibody interaction can well be envisaged to cause dysfunction of the target protein, including internalization. Others, such as antibodies directed against GAD65 (an intracellular enzyme responsible for GABA-synthesis from glutamate), are discussed to constitute epiphenomena, but not causal agents in disease progression. This review will focus on the current knowledge of antibody interaction mechanisms, especially discussing cellular excitability changes and synaptic interactions in hippocampal and other brain networks. One challenge in this context is to find viable hypotheses for the emergence of both, hyperexcitability and seizures, and presumably reduced synaptic plasticity and underlying cognitive dysfunction.
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Affiliation(s)
- Timo Kirschstein
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany; Center for Translational Neuroscience Research, Rostock University Medical Center, 18057 Rostock, Germany
| | - Rüdiger Köhling
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Gertrudenstraße 9, 18057 Rostock, Germany; Center for Translational Neuroscience Research, Rostock University Medical Center, 18057 Rostock, Germany.
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Meng Y, Shen HL. Role of N-Methyl-D-Aspartate Receptor NR2B Subunit in Inflammatory Arthritis-Induced Chronic Pain and Peripheral Sensitized Neuropathic Pain: A Systematic Review. J Pain Res 2022; 15:2005-2013. [PMID: 35880050 PMCID: PMC9307865 DOI: 10.2147/jpr.s367982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022] Open
Abstract
Arthritis is a common clinical disease that affects millions of people in the world. The most common types of arthritis are osteoarthritis and rheumatoid arthritis. Inflammatory arthritis (IA), a chronic painful disease, is characterized by synovitis and cartilage destruction in the early stages. Pathologically, IA causes inflammatory changes in the joints and eventually leads to joint destruction. Pain is associated with inflammation and abnormal regulation of the nervous system pathways involved in pain promotion and inhibition. In addition, the occurrence of pain is associated with depression and anxiety. We found that there are many factors affecting pain, in addition to inflammatory factors, glutamate receptor may be the possible cause of long-term chronic pain caused by IA. N-methyl-d-aspartate receptor subunit 2B (NR2B) has been reported to involved in IA and nervous system diseases, especially peripheral neuropathic pain. In this review, we summarized the mechanisms of the NR2B subunit of the N-methyl-D-aspartate (NMDA) receptor in peripheral nerve sensitization during IA and chronic pain.
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Affiliation(s)
- Yu Meng
- Department of Pain, The Lanzhou University Second Hospital, Lanzhou, People's Republic of China
| | - Hai Li Shen
- Department of Rheumatology and Immunology, The Lanzhou University Second Hospital, Lanzhou, People's Republic of China
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Pan J, Ovlyakulov B, Zhou L. Overlapping anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis with neuromyelitis optica spectrum disorders: a case report. Eur J Med Res 2022; 27:66. [PMID: 35527314 PMCID: PMC9082901 DOI: 10.1186/s40001-022-00697-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 05/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis can coexist with neuromyelitis optica spectrum disorder (NMOSD). Patients with overlapping anti-NMDAR encephalitis with positive NMDAR antibodies and aquaporin 4 immunoglobulin G (AQP4-IgG)-seropositive NMOSD are rare but should not be ignored. Case presentation This report describes a unique case of anti-NMDAR encephalitis coexisting with NMOSD. A 27-year-old male presented with blurred vision, cognitive impairment, psychosis, dysphagia, gait instability and urinary incontinence. Brain magnetic resonance imaging (MRI) showed abnormal signals in the right cerebellar hemisphere, temporal lobe, and corpus callosum. NMDAR antibodies were positive in the CSF. AQP4-IgG antibodies were positive in the serum. The patient's condition was stable following intravenous gamma globulin, corticosteroids, immunosuppressants and symptomatic treatments. Conclusions This case provides further evidence for the occurrence of anti-NMDAR encephalitis overlapping NMOSD with AQP4-IgG-seropositive in a Chinese patient. However, the mechanisms underlying the occurrence of double-positive antibodies remain elusive.
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Llerena-Rengel PA, Villamarín-Granja LF, Vélez-Páez JL. Schizophrenia and refractory status epilepticus in a male patient with anti-NMDA auto-immune encephalitis: A case report. BIONATURA 2021. [DOI: 10.21931/rb/2021.06.04.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Encephalitis is the inflammation of the central nervous system cells as a result of activation of immune cells, antibodies, or proteins by a reaction with pathogens or self-body components; when this happens, a malfunction of the immune system is known as this an auto-immune disease. Auto-immune encephalitis characterizes 21% of all encephalitis and manifests with loss of memory and cognition, personality deviations, neurologic deficit, aphasia, seizures, and epilepsy. Treatment is guaranteed using steroids, immunoglobulins, and plasmapheresis, and as a second-line therapy, cyclophosphamide or rituximab is used. In cases related to tumors, surgery is part of the treatment. An unusual case of auto-immune encephalitis is reported.
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Affiliation(s)
| | | | - Jorge Luis Vélez-Páez
- Universidad Central del Ecuador-Instituto Superior de Posgrado, Quito-Ecuador. Hospital Pablo Arturo Suárez-Unidad de Terapia Intensiva-Centro de Investigación Clínica, Quito-Ecuador
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9
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The Association of Ovarian Teratoma and Anti-N-Methyl-D-Aspartate Receptor Encephalitis: An Updated Integrative Review. Int J Mol Sci 2021; 22:ijms222010911. [PMID: 34681570 PMCID: PMC8535897 DOI: 10.3390/ijms222010911] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/26/2021] [Accepted: 10/07/2021] [Indexed: 01/09/2023] Open
Abstract
Ovarian teratomas are by far the most common ovarian germ cell tumor. Most teratomas are benign unless a somatic transformation occurs. The designation of teratoma refers to a neoplasm that differentiates toward somatic-type cell populations. Recent research shows a striking association between ovarian teratomas and anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, a rare and understudied paraneoplastic neurological syndrome (PNS). Among teratomas, mature teratomas are thought to have a greater relevance with those neurological impairments. PNS is described as a neurologic deficit triggered by an underlying remote tumor, whereas anti-NMDAR encephalitis is characterized by a complex neuropsychiatric syndrome and the presence of autoantibodies in cerebral spinal fluid against the GluN1 subunit of the NMDAR. This review aims to summarize recent reports on the association between anti-NMDAR encephalitis and ovarian teratoma. In particular, the molecular pathway of pathogenesis and the updated mechanism and disease models would be discussed. We hope to provide an in-depth review of this issue and, therefore, to better understand its epidemiology, diagnostic approach, and treatment strategies.
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El Hanna J, Quenum C, Arsalane A. Anti-NMDAR encephalitis in a 19 year old female patient with ovarian teratoma: A case report. Eur J Obstet Gynecol Reprod Biol X 2021; 11:100129. [PMID: 34195605 PMCID: PMC8237288 DOI: 10.1016/j.eurox.2021.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/07/2021] [Indexed: 11/01/2022] Open
Abstract
Background Anti-N-Methyl-d-Aspartate encephalitis is a subcategory of auto-immune encephalitis. It is known for its aggressive presenting symptoms and rapid deterioration, yet it is treatment responsive. It is associated in 50 % to ovarian teratoma. Case We report the case of a 19 year old female patient presenting for a psychiatric disorder of sudden onset with rapid deterioration. Neurologic imaging was in favor of encephalitis, and CSF studies revealed Anti NMDA receptors. Further abdominal imaging showed a right ovarian teratoma of 4 cm.Laparoscopic ovarian cyst resection was done, and corticotherapy, IVIG and anticonvulsants were given. We report complete resolution of symptoms after 7 months. Conclusion Anti-NMDA receptor encephalitis with ovarian teratoma is a rare entity with rapid deterioration. Early diagnosis, surgical resection and proper medical treatment are essential for the management of this disease.
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Affiliation(s)
- Johnny El Hanna
- Department of Obstetrics and Gynecology, Grand Hôpital de l'Est Francilien, France
| | - Codjo Quenum
- Department of Obstetrics and Gynecology, Grand Hôpital de l'Est Francilien, France
| | - Abdelilah Arsalane
- Department of Obstetrics and Gynecology, Grand Hôpital de l'Est Francilien, France
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Rakiro J, Sokhi D. Fatal Autoimmune Anti-NMDA-Receptor Encephalitis with Poor Prognostication Score in a Young Kenyan Female. Int Med Case Rep J 2021; 14:343-347. [PMID: 34079388 PMCID: PMC8164334 DOI: 10.2147/imcrj.s311071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
Auto-immune N-methyl-D-aspartate receptor encephalitis (NMDARE) is a relatively recently described cause of acute encephalopathy with very few reports from sub-Saharan Africa (SSA). We report a case of NMDARE in a young Kenyan female who was transferred to our facility with headaches, insomnia, behaviour changes and latterly pathognomonic orofacial dyskinesias. We comprehensively ruled out infectious and other inflammatory/auto-immune causes. She was diagnosed with NMDARE by positive antibody testing in serum and cerebrospinal fluid and changes on brain magnetic resonance imaging. She was immunosuppressed with high-dose steroids, intravenous immunoglobulins, plasma exchange and rituximab, and showed signs of neurological improvement clinically and radiologically. Unfortunately, she succumbed to septic shock from prolonged intensive care. This is the first report of NMDARE in an indigenous patient from the eastern SSA. The majority (>80%) of patients are either left with mild disability or make a full recovery after NMDARE, but some factors – which comprise the NMDARE One-Year Functional Status (NEOS) prognostication score – can adversely affect outcome, as was the case in our patient.
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Affiliation(s)
- Joe Rakiro
- Department of Medicine, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Dilraj Sokhi
- Department of Medicine, Aga Khan University Medical College of East Africa, Nairobi, Kenya
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12
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Ursitti F, Roberto D, Papetti L, Moavero R, Ferilli MAN, Fusco L, Vigevano F, Curatolo P, Valeriani M. Diagnosis of pediatric anti-NMDAR encephalitis at the onset: A clinical challenge. Eur J Paediatr Neurol 2021; 30:9-16. [PMID: 33321446 DOI: 10.1016/j.ejpn.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 11/26/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUNDS To investigate the clinical and instrumental features at the onset addressing to the diagnosis of anti-NMDAR encephalitis. METHODS Twenty children (age: 15 months-17 years; 7 males, 13 females) with initial suspected diagnosis of autoimmune encephalitis, observed between January 2008 and March 2018, were included. The final diagnosis was anti-NMDAR encephalitis in 7 children, other/probable autoimmune encephalitis in 7 children, and primary psychosis in the remaining 6 children. RESULTS At the clinical onset, anxiety disorder was the main symptom that helped in distinguishing the group of psychotic children from children with non-infectious encephalitis (P = 0.05 OR = 0.001), while epileptic seizures strongly predicted anti-NMDAR encephalitis (P = 0.04 OR = 28.6). At the onset, anti-NMDAR encephalitis could be distinguished from other/probable autoimmune encephalitis for the presence of sleep/wake rhythm alteration (P = 0.05 OR = 15). Among the symptoms occurring during the hospitalization, movement disorders (P = 0.031 OR = 12) were predictive of non-infectious encephalitis rather than primary psychosis. More specifically, the occurrence of language impairment (P = 0.03 OR = 33), epileptic seizures (P = 0.04 OR = 28.6) and catatonia (P = 0.03, OR = 33), were predictive of anti-NMDAR encephalitis. Also at this stage, anxiety disorder (P = 0.03 OR = 0.033) was predictive of primary psychosis. CONCLUSION Our findings suggest that at the clinical onset epileptic seizures and sleep/wake rhythm alteration represent the main features addressing to the diagnosis of anti-NMDAR encephalitis rather than primary psychosis and other/probable autoimmune encephalitis, while anxiety disorder could be a solid predictor of primary psychosis.
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Affiliation(s)
- F Ursitti
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy
| | - D Roberto
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital of Rome, Rome, Italy
| | - L Papetti
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy
| | - R Moavero
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy; Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital of Rome, Rome, Italy
| | - M A N Ferilli
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy
| | - L Fusco
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy
| | - F Vigevano
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy
| | - P Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital of Rome, Rome, Italy
| | - M Valeriani
- Department of Neurological and Psychiatric Sciences, Bambino Gesù Children Hospital, Rome, Italy; Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark.
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Putative Autoantigen Leiomodin-1 Is Expressed in the Human Brain and in the Membrane Fraction of Newly Formed Neurons. Pathogens 2020; 9:pathogens9121036. [PMID: 33321732 PMCID: PMC7763904 DOI: 10.3390/pathogens9121036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/21/2022] Open
Abstract
Nodding syndrome is a pediatric epilepsy disorder associated with Onchocerca volvulus infection, but the mechanism driving this relationship is unclear. One hypothesis proposes that parasite-induced immune responses cross-react with human leiomodin-1 resulting in immune-mediated central nervous system (CNS) damage. However, as leiomodin-1 expression and epitope availability in human neurons remains uncharacterized, the relevance of leiomodin-1 autoimmunity is unknown. Leiomodin-1 transcript expression was assessed in silico using publicly available ribonucleic acid (RNA) sequencing databases and in tissue by in situ hybridization and quantitative polymerase chain reaction. Abundance and subcellular localization were examined by cell fractionation and immunoblotting. Leiomodin-1 transcripts were expressed in cells of the CNS, including neurons and astrocytes. Protein was detectable from all brain regions examined as well as from representative cell lines and in vitro differentiated neurons and astrocytes. Leiomodin-1 was expressed on the membrane of newly formed neurons, but not neural progenitor cells or mature neurons. Importantly, leiomodin-1 antibodies were only toxic to cells expressing leiomodin-1 on the membrane. Our findings provide evidence that leiomodin-1 is expressed in human neurons and glia. Furthermore, we show membrane expression mediates leiomodin-1 antibody toxicity, suggesting these antibodies may play a role in pathogenesis.
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do Valle DA, Santos MLSF, Zeny MS, Cordeiro ML. Pediatric Anti-N-methyl-D-aspartate Receptor Encephalitis Mimicking Glutaric Aciduria Type 1: A Case Report. Front Neurol 2020; 11:587324. [PMID: 33193053 PMCID: PMC7649249 DOI: 10.3389/fneur.2020.587324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/17/2020] [Indexed: 01/17/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated disease that induces a wide spectrum of symptoms, especially in toddlers. These include acute-onset movement disorders, with neurological regression, and other associated neurological symptoms. Anti-NMDAR encephalitis remains a diagnostic challenge, especially in toddlers, with better prognosis associated with early treatment. We report the case of a 15-months-old boy who initially presented with vomiting and later with acute-onset dystonia after the administration of antiemetics. Within 14 days, the patient developed neuropsychomotor developmental regression and worsening dystonia. After ruling out an acute dystonic reaction and glutaric acidemia type 1 (GA-1), a final diagnosis of anti-NMDAR encephalitis was made. The patient responded well to immunomodulatory therapy. The present case underscores the importance of early treatment for patient prognosis and of including anti-NMDAR encephalitis in the differential diagnosis of acute-onset movement disorders.
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Affiliation(s)
- Daniel Almeida do Valle
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Mara Lúcia Schmitz Ferreira Santos
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Michelle Silva Zeny
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Mara L Cordeiro
- Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, LA, United States
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15
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Belova AN, Grygorieva VN, Rasteryaeva MV, Ruina EA, Belova EM, Solovieva VS, Boyko AN. [Anti-NMDAR encephalitis associated with relapsing optic neuritis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:105-113. [PMID: 32678556 DOI: 10.17116/jnevro2020120061105] [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: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A N Belova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - V N Grygorieva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Ruina
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E M Belova
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
| | - V S Solovieva
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
| | - A N Boyko
- Federal Center of Cerebrovascular Pathology and Stroke of Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain and Neurotechnologies, Moscow, Russia
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16
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VanDongen-Trimmer H, Sannagowdara K, Balakrishnan B, Farias-Moeller R. A Case of HIV Seroconversion Presenting Similarly to Anti-N-methyl-D-aspartate Receptor Encephalitis. Neurocrit Care 2020; 31:423-427. [PMID: 31410769 DOI: 10.1007/s12028-019-00805-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Heather VanDongen-Trimmer
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Kumar Sannagowdara
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Binod Balakrishnan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA. .,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA.
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17
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Current Progress on Assessing the Prognosis for Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7506590. [PMID: 32352007 PMCID: PMC7178504 DOI: 10.1155/2020/7506590] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/01/2020] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most common antineuronal antibody encephalitis in autoimmune encephalitis found at present. It has complex clinical manifestations such as psychiatric and behavioral abnormalities, seizures, movement disorders, consciousness, and autonomic dysfunction. The relationship between those manifestations and prognosis is unclear. Electroencephalography (EEG) is gradually becoming useful in the evaluation of the prognosis of anti-NMDAR encephalitis patients, while imaging and antibody testing have a limited prognostic value. Starting the patients on adequate treatments (such as immunotherapy) in a timely fashion has a positive impact on their prognosis. Nevertheless, research on the prognosis of anti-NMDAR encephalitis remains scarce. Here, we review the current advances of prognosis-related research from the clinical manifestations of the disease and auxiliary examinations such as EEG, magnetic resonance imaging (MRI), 18F fluorodeoxyglucose positron emission tomography (FDG-PET), and antibody measurement. In addition, we also discuss the impact of different treatment options on prognosis. In-depth research on the prognosis of patients with anti-NMDAR encephalitis will contribute to a better understanding of this disease, leading to better treatments options and, ultimately, a better prognosis.
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18
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Belova AN, Grygorieva VN, Rasteryaeva MV, Ruina EA, Belova EM, Solovieva VS, Boyko AN. [Anti-NMDAR encephalitis associated with relapsing optic neuritis: a case report and differential diagnosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 119:137-146. [PMID: 31934999 DOI: 10.17116/jnevro201911910137] [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: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A N Belova
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - V N Grygorieva
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - E A Ruina
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - E M Belova
- State Budgetary Healthcare Institute 'City Clinical Hospital #3', Nizhny Novgorod, Russia
| | - V S Solovieva
- State Budgetary Healthcare Institute 'City Clinical Hospital #3', Nizhny Novgorod, Russia
| | - A N Boyko
- Pirogov National Russian Scientific Medical University, Moscow, Russia; Federal Center of Cerebrovascular Pathology and Stroke, Moscow, Russia
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19
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Valdoleiros SR, Calejo M, Marinho A, Martins da Silva A, Vasconcelos O, Gonçalves MJ, Sarmento E Castro R. First report of concomitant cryptococcal meningitis and anti-NMDAR encephalitis. Brain Behav Immun Health 2020; 2:100036. [PMID: 34589827 PMCID: PMC8474238 DOI: 10.1016/j.bbih.2020.100036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 11/25/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder, seen most often in young adults and children, triggered by tumors or infections. We report a case of cryptococcal meningitis in a patient with sarcoidosis, presenting prominent neuropsychiatric symptoms, electroencephalographic features of autoimmune encephalitis and positive anti-NMDAR antibodies in the cerebrospinal fluid, raising the hypothesis of an infectious immune-mediated mechanism triggering the production of anti-NMDAR antibodies. Since anti-NMDAR encephalitis is potentially fatal and has significant morbidity, further descriptions of its etiological associations are essential to early identification and prompt treatment. Cryptococcal meningitis is a rare complication of sarcoidosis and CD4 lymphopenia. Anti-NMDAR encephalitis is an autoimmune disorder triggered by tumors or infection. A case of concomitant cryptococcosis and anti-NMDAR encephalitis is presented.
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Affiliation(s)
- Sofia R Valdoleiros
- Department of Infectious Diseases, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Margarida Calejo
- Department of Neurology, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - António Marinho
- Department of Internal Medicine, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, 4099-001, Porto, Portugal
| | - Ana Martins da Silva
- Department of Neurology, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, 4099-001, Porto, Portugal
| | - Olga Vasconcelos
- Department of Infectious Diseases, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Maria João Gonçalves
- Department of Infectious Diseases, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Rui Sarmento E Castro
- Department of Infectious Diseases, Centro Hospitalar Universitário do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
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20
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Are We Missing Subtle Forms of Anti-N-Methyl-D-Aspartate Encephalitis With the Current Diagnostic Approach? A Case Report. J Psychiatr Pract 2019; 25:383-390. [PMID: 31505524 DOI: 10.1097/pra.0000000000000412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Encephalitis related to antibodies against the N-methyl-D-aspartate receptor (NMDAr) is a recently described clinical entity in which IgG autoantibodies against the NR1 subunit of the NMDAr lead to the appearance of complex neuropsychiatric symptoms. As psychiatric symptoms predominate in early stages, anti-NMDAr encephalitis is frequently mistaken as a primary psychiatric disorder which delays treatment and has serious consequences for patients. This report presents the case of a 24-year-old woman with a subacute onset of psychotic and catatonic symptoms in whom current diagnostic criteria for probable anti-NMDAr encephalitis were not fulfilled. On the basis of the red flags that have been proposed to raise suspicion of anti-NMDAr encephalitis, a study of fluorodeoxyglucose positron emission tomography was requested and demonstrated bilateral occipital hypometabolism consistent with clinical suspicion of anti-NMDAr encephalitis. Once the appropriate treatment was established, the patient recovered completely. This case supports the need to maintain clinical suspicion of anti-NMDAr encephalitis, even when conventional diagnostic tests have been normal. Psychiatrists should be familiar with this entity to promote timely diagnosis and prompt treatment.
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21
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Commentary on "Are We Missing Subtle Forms of Anti-N-Methyl-D-Aspartate Encephalitis With the Current Diagnostic Approach? A Case Report". J Psychiatr Pract 2019; 25:383-390. [PMID: 31505525 DOI: 10.1097/pra.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Encephalitis related to antibodies against the N-methyl-D-aspartate receptor (NMDAr) is a recently described clinical entity in which IgG autoantibodies against the NR1 subunit of the NMDAr lead to the appearance of complex neuropsychiatric symptoms. As psychiatric symptoms predominate in early stages, anti-NMDAr encephalitis is frequently mistaken as a primary psychiatric disorder which delays treatment and has serious consequences for patients. This report presents the case of a 24-year-old woman with a subacute onset of psychotic and catatonic symptoms in whom current diagnostic criteria for probable anti-NMDAr encephalitis were not fulfilled. On the basis of the red flags that have been proposed to raise suspicion of anti-NMDAr encephalitis, a study of fluorodeoxyglucose positron emission tomography was requested and demonstrated bilateral occipital hypometabolism consistent with clinical suspicion of anti-NMDAr encephalitis. Once the appropriate treatment was established, the patient recovered completely. This case supports the need to maintain clinical suspicion of anti-NMDAr encephalitis, even when conventional diagnostic tests have been normal. Psychiatrists should be familiar with this entity to promote timely diagnosis and prompt treatment.
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22
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Baten A, Desai M, Melo-Bicchi M, Gutierrez C. Continuous Electroencephalogram as a Biomarker of Disease Progression and Severity in Herpes Simplex Virus-1 Encephalitis. Clin EEG Neurosci 2019; 50:361-365. [PMID: 30873853 DOI: 10.1177/1550059419835705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective. Herpes simplex virus encephalitis (HSE) is the most common cause of sporadic fatal encephalitis worldwide and remains a devastating disease despite antiviral therapy. EEG can be an important tool in the diagnosis of HSE, and we propose that it can be used to monitor the progression of the disease in patients with treatment refractory HSE. Methods. This is a case report of a patient with HSE who was monitored on continuous EEG (CEEG) throughout course of her disease. Results. A 62-year-old woman with no history of neurologic disease, who presented with generalized weakness and lethargy for 2 weeks, and rapidly deteriorated with encephalopathy, fever, and seizures. Lumbar puncture demonstrated elevated protein and white blood cells with positive herpes simplex virus (HSV) DNA. CEEG initially showed right-sided lateralized periodic discharges and focal seizures/status epilepticus with shifting predominance, and then later progressed to be more focal on the left, and then progressed to demonstrating more generalized findings. Magnetic resonance imaging obtained 3 times confirmed what CEEG heralded with evolution from prior studies which were concordant with CEEG, suggesting disease spread. Significance. We report the case of a patient with HSE who was monitored on CEEG and propose that CEEG can be used as a marker for progression of disease and thus may prompt escalation in therapy. While imaging studies may confirm spread of disease, using CEEG may prevent the delay of treatment and lead to more rapid therapy in cases of refractory HSE.
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Affiliation(s)
- Ahmareen Baten
- 1 Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Masoom Desai
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Miguel Melo-Bicchi
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Camilo Gutierrez
- 2 Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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23
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Anti-N-Methyl-D-Aspartate Encephalitis as Paraneoplastic Manifestation of Germ-Cells Tumours: A Cases Report and Literature Review. Case Reports Immunol 2019; 2019:4762937. [PMID: 30963010 PMCID: PMC6431454 DOI: 10.1155/2019/4762937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 11/18/2022] Open
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common form of autoimmune encephalitis, caused by the interaction between an antibody and its target, located on glutamate receptor type N-methyl-D-aspartate (NMDA) of neuronal surface. There is a wide spectrum of clinical features starting by a viral-like prodrome, followed by symptoms such as psychosis, aggressive behaviour, memory loss, seizures, movement disorders, and autonomic instability. Up to 50% of the affected young female patients have germ-cells tumours as ovarian teratoma, making it essential to establish an early diagnosis through detection of specific antibodies in serum and cerebrospinal fluid (CSF). This retrospective observational study was performed in patients whom positive anti-NMDA receptor antibodies have been tested, associated with clinical manifestations that suggest autoimmune encephalitis and a germ-cell tumour confirmed by pathology. Six patients have tested positive for anti-NMDA receptor antibodies associated with a germ-cell tumour and clinical manifestations of autoimmune encephalitis. Management includes aggressive immunosuppression and surgical removal.
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24
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Wang HY, Li T, Li XL, Zhang XX, Yan ZR, Xu Y. Anti-N-methyl-D-aspartate receptor encephalitis mimics neuroleptic malignant syndrome: case report and literature review. Neuropsychiatr Dis Treat 2019; 15:773-778. [PMID: 31040676 PMCID: PMC6452791 DOI: 10.2147/ndt.s195706] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a severe autoimmune disease characterized by complicated psychiatric and neurological symptoms and a difficult diagnosis. This disorder is commonly misdiagnosed, and diagnosis is often delayed. The clinical signs can mimic other psychiatric abnormalities, such as neuroleptic malignant syndrome (NMS) that is usually caused by antipsychotic exposure. This fact raises the question of whether the symptoms common to NMS are due to anti-NMDA receptor encephalitis or established NMS. CASES PRESENTATION We describe a rare case of a 29-year-old male without psychiatric history who initially presented with a fever, altered consciousness, behavioral changes, rigidity, and elevated creatine kinase. He was initially diagnosed with NMS. NMS-like symptoms did not improve with active treatments and disappeared for a long period after discontinuing antipsychotics. The patient gradually developed a complicated disease progression, including speech impairment, mutism, and movement disorders, and symptom progression led to the final diagnosis of anti-NMDA receptor encephalitis. The related pathophysiological mechanisms, clinical features, and treatment of this disease are reviewed. CONCLUSION We highlight that the natural progress of anti-NMDA receptor encephalitis can mimic the symptoms of NMS and NMS-like features could be due to anti-NMDA receptor encephalitis upon antipsychotic exposure, and not true NMS. Clinically, the suspicion of NMS may serve as a significant alarm to suspect anti-NMDA receptor encephalitis and lead neurologists or psychiatrists to investigate such a diagnosis.
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Affiliation(s)
- Hai-Yang Wang
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Tian Li
- Department of Cardiology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China.,Department of Internal Medicine-Cardiovascular, Qilu Hospital of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Xue-Lin Li
- Department of Intensive Care Unit, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China
| | - Xiao-Xia Zhang
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Zhong-Rui Yan
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Yang Xu
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
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25
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Martinez HR, Olguin-Ramirez LA, Camara-Lemarroy CR. Lyme borreliosis as a trigger for NMDA receptor encephalitis? Neurol Sci 2018; 39:1815-1817. [PMID: 30008117 DOI: 10.1007/s10072-018-3497-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/09/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Hector R Martinez
- Instituto de Neurologia y Neurocirugía, Tecnologico de Monterrey, Hospital Zambrano Hellion, Batallon de San Patricio 112 Colonia Residencial San Agustin, 66278, San Pedro Garza Garcia, N.L., Mexico. .,Servicio de Neurología, Hospital Universitario Universidad Autónoma de Nuevo León (UANL), Monterrey, Mexico.
| | - Leticia A Olguin-Ramirez
- Instituto de Neurologia y Neurocirugía, Tecnologico de Monterrey, Hospital Zambrano Hellion, Batallon de San Patricio 112 Colonia Residencial San Agustin, 66278, San Pedro Garza Garcia, N.L., Mexico
| | - Carlos R Camara-Lemarroy
- Instituto de Neurologia y Neurocirugía, Tecnologico de Monterrey, Hospital Zambrano Hellion, Batallon de San Patricio 112 Colonia Residencial San Agustin, 66278, San Pedro Garza Garcia, N.L., Mexico.,Servicio de Neurología, Hospital Universitario Universidad Autónoma de Nuevo León (UANL), Monterrey, Mexico.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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26
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Opazo MC, Ortega-Rocha EM, Coronado-Arrázola I, Bonifaz LC, Boudin H, Neunlist M, Bueno SM, Kalergis AM, Riedel CA. Intestinal Microbiota Influences Non-intestinal Related Autoimmune Diseases. Front Microbiol 2018; 9:432. [PMID: 29593681 PMCID: PMC5857604 DOI: 10.3389/fmicb.2018.00432] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/26/2018] [Indexed: 12/16/2022] Open
Abstract
The human body is colonized by millions of microorganisms named microbiota that interact with our tissues in a cooperative and non-pathogenic manner. These microorganisms are present in the skin, gut, nasal, oral cavities, and genital tract. In fact, it has been described that the microbiota contributes to balancing the immune system to maintain host homeostasis. The gut is a vital organ where microbiota can influence and determine the function of cells of the immune system and contributes to preserve the wellbeing of the individual. Several articles have emphasized the connection between intestinal autoimmune diseases, such as Crohn's disease with dysbiosis or an imbalance in the microbiota composition in the gut. However, little is known about the role of the microbiota in autoimmune pathologies affecting other tissues than the intestine. This article focuses on what is known about the role that gut microbiota can play in the pathogenesis of non-intestinal autoimmune diseases, such as Grave's diseases, multiple sclerosis, type-1 diabetes, systemic lupus erythematosus, psoriasis, schizophrenia, and autism spectrum disorders. Furthermore, we discuss as to how metabolites derived from bacteria could be used as potential therapies for non-intestinal autoimmune diseases.
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Affiliation(s)
- Maria C Opazo
- Laboratorio de Biología Celular y Farmacología, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Universidad Andres Bello, Santiago, Chile.,Facultad de Medicina, Millennium Institute on Immunology and Immunotherapy, Universidad Andres Bello, Santiago, Chile
| | - Elizabeth M Ortega-Rocha
- Laboratorio de Inmunobiología, Facultad de Medicina, Departamento de Biología Celular y Tisular, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Irenice Coronado-Arrázola
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Laura C Bonifaz
- Unidad de Investigación Médica en Inmunoquímica Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Helene Boudin
- Institut National de la Santé et de la Recherche Médicale U1235, Institut des Maladies de l'Appareil Digestif, Université de Nantes, Nantes, France
| | - Michel Neunlist
- Institut National de la Santé et de la Recherche Médicale U1235, Institut des Maladies de l'Appareil Digestif, Université de Nantes, Nantes, France
| | - Susan M Bueno
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexis M Kalergis
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad, Metropolitana, Chile
| | - Claudia A Riedel
- Laboratorio de Biología Celular y Farmacología, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Universidad Andres Bello, Santiago, Chile.,Facultad de Medicina, Millennium Institute on Immunology and Immunotherapy, Universidad Andres Bello, Santiago, Chile
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