1
|
Zhang Y, Cheng YK, Yang CF, Jin LM, Li YM. Therapeutic plasma exchange in anti-N-methyl-D-aspartate receptor encephalitis. Ther Apher Dial 2023; 27:197-206. [PMID: 36165337 DOI: 10.1111/1744-9987.13934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/05/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is the most commonly identified cause of autoimmune encephalitis. Therapeutic plasma exchange has been increasingly employed to treat this disease. This expansion is a consequence of improved techniques and apheresis instruments, as well as the recognition of its applicability in neurological diseases. However, several aspects of treatment remain incompletely clarified, and treatment strategies are still heterogeneous, especially with regard to therapeutic plasma exchange in anti-NMDAR encephalitis. This review provides an overview of the use of therapeutic plasma exchange including the principle and mechanisms, the evidence, initial time, efficiency and complications in anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Yuan Zhang
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Jilin, China
| | - Yong-Kang Cheng
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Jilin, China
| | - Chun-Feng Yang
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Jilin, China
| | - Lin-Mei Jin
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Jilin, China
| | - Yu-Mei Li
- Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Jilin, China
| |
Collapse
|
2
|
Saengow VE, Bhudhisawasdi K. Outcome of Pediatric Anti-N-Methyl-D-Aspartate (NMDA) Receptor Encephalitis in Rural Area of Thailand. JOURNAL OF CHILD SCIENCE 2022. [DOI: 10.1055/s-0042-1757144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractAnti-N-methyl-d-aspartate receptor (NMDAR) encephalitis has a very good outcome; however, there are few reports in developing countries regarding the outcome of pediatric anti-NMDAR encephalitis. We aimed to report the clinical outcome of pediatric anti-NMDAR encephalitis in the rural area of Thailand. This retrospective cohort study recruited children between the age of 1 month and 15 years with the diagnosis of anti-NMDAR encephalitis admitted at Maharat Nakhon Ratchasima Hospital from 1st May 2015 to 31th March 2020. Baseline characteristics and investigation were recorded. The first-line treatment was intravenous pulse methylprednisolone alone, pulse methylprednisolone plus intravenous immune globulin (IVIG), or IVIG alone. The second-line treatment was monthly intravenous cyclophosphamide or azathioprine. The modified Rankin Scale (MRS) was used for evaluation at 1, 3, 6, 12, 18, and 24 months after receiving first-line treatment to determine clinical outcomes. The factors that may affect the outcomes were evaluated. In total, 17 patients were recruited, with the mean age of 8 years, and 76.46% were female. 82.35% of patients developed seizures, and 52.94% turned to status epilepticus. 70.59% received first-line treatment as pulse methylprednisolone plus IVIG. 82.35% received complete follow-up at 12 months. According to MRS score, at first diagnosis 94.12% reported severe disability, at 1 month after receiving treatment, 47.06% improved to moderate–mild disability, and at 6 and 12 months, 40% and 78.57% had complete recovery, respectively. Different types of first-line and second-line treatments did not affect the clinical outcome. Comorbidity of status epilepticus affected MRS. Anti-NMDAR encephalitis has a very good prognosis; prompt diagnosis is necessary. Comorbidity as status epilepticus may affect the clinical outcome.
Collapse
|
3
|
Barbadillo AFP, Quimpo RAS, Sanchez-Gan B. Case of anti-NMDA receptor encephalitis in a female adolescent with favourable response to second-line treatment with cyclophosphamide. BMJ Case Rep 2022; 15:e249991. [PMID: 36007966 PMCID: PMC9422838 DOI: 10.1136/bcr-2022-249991] [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] [Indexed: 11/04/2022] Open
Abstract
We report the case of a female adolescent who presented with behavioural changes. She was admitted to our institution due to worsening psychiatric and neurological symptoms, subsequently diagnosed with anti-N-methyl-D-aspartate receptor encephalitis. Additional workup was facilitated to rule out a possible underlying teratoma, but all tests turned out unremarkable. First-line treatment with methylprednisolone pulse therapy and intravenous immunoglobulin was started, to which she showed marked improvement from baseline. One month after discharge, a decision for readmission was made because of persistent episodes of hallucinations, agitation and dyskinesias. In this case report, we highlight the use of cyclophosphamide over rituximab as second-line treatment in a resource-limited setting, owing to its greater availability and lesser cost. Cyclophosphamide treatment was given resulting in a more sustained clinical improvement with return to baseline function.
Collapse
Affiliation(s)
| | - Rhea Angela Salonga Quimpo
- Department of Neurosciences, Department of Pediatrics, University of the Philippines Manila, Manila, Philippines
| | - Benilda Sanchez-Gan
- Department of Neurosciences, Department of Pediatrics, University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
4
|
Cascardo C, Ismail A, Fullmer J, Davila F. Anti-NMDA receptor encephalitis with initial negative markers: diagnostic and therapeutic challenges of a refractory case with 9-month-long follow-up. BMJ Case Rep 2022; 15:e249126. [PMID: 35764337 PMCID: PMC9240890 DOI: 10.1136/bcr-2022-249126] [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] [Indexed: 11/06/2022] Open
Abstract
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a progressively debilitating, frequently fatal disease caused by autoantibodies against the NMDA receptor. Risk of delayed treatment is high due to variable presentations, lack of awareness and potential false negative diagnostic studies. In this case report, a woman in her 20s presented with psychiatric manifestations and rapidly declined. Dyskinetic movements and dysautonomia were observed. Initial cerebrospinal fluid and serum anti-NMDA receptor antibodies were negative. MRI was inconclusive. Electroencephalography demonstrated extreme delta brush. Pelvic CT revealed an adnexal teratoma. She remained refractory to treatment until day 126 when, after two cycles of cyclophosphamide, she started to improve. She participated in rehabilitation with eventual discharge home on day 269. Recognising the variable presentations of anti-NMDA receptor encephalitis is important in avoiding misdiagnosis and delayed treatment. If clinical suspicion remains high despite negative results, repeat testing should be pursued. Clinical response should guide treatment decisions in refractory cases.
Collapse
Affiliation(s)
- Camilla Cascardo
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | | | - Joseph Fullmer
- Pathology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Francisco Davila
- Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| |
Collapse
|
5
|
Shahrestani S, Brown NJ, Singh R, Kurtz JS, Patel NA, Himstead AS, Nasrollahi T, Borrelli M, Pierzchajlo N, Ransom SC, Gendreau J. Evaluating the incidence and predictors of anti-NMDAR encephalitis in a contemporary cohort of patients diagnosed with dermoid tumors: A national inpatient sample analysis. J Clin Neurosci 2022; 102:109-113. [PMID: 35777113 DOI: 10.1016/j.jocn.2022.06.018] [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: 03/25/2022] [Revised: 06/02/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, CA, USA
| | - Rohin Singh
- School of Medicine, University of California, Irvine, CA, USA
| | - Joshua S Kurtz
- School of Medicine, University of California, Irvine, CA, USA
| | - Neal A Patel
- Mercer University School of Medicine, Macon, GA, USA
| | | | - Tasha Nasrollahi
- Department of Otolaryngology, Head and Neck Surgery, Cedars Sinai School of Medicine, Los Angeles, CA, USA
| | - Michela Borrelli
- Department of Otolaryngology, Head and Neck Surgery, Cedars Sinai School of Medicine, Los Angeles, CA, USA
| | | | - Seth C Ransom
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| |
Collapse
|
6
|
Stathopoulos P, Dalakas MC. Evolution of Anti-B Cell Therapeutics in Autoimmune Neurological Diseases. Neurotherapeutics 2022; 19:691-710. [PMID: 35182380 PMCID: PMC9294112 DOI: 10.1007/s13311-022-01196-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 02/08/2023] Open
Abstract
B cells have an ever-increasing role in the etiopathology of a number of autoimmune neurological disorders, acting as antigen-presenting cells facilitating antibody production but also as sensors, coordinators, and regulators of the immune response. In particular, B cells can regulate the T cell activation process through their participation in antigen presentation, production of proinflammatory cytokines (bystander activation or suppression), and contribution to ectopic lymphoid aggregates. Such an important interplay between B and T cells makes therapeutic depletion of B cells an attractive treatment strategy. The last decade, anti-B cell therapies using monoclonal antibodies against B cell surface molecules have evolved into a rational approach for successfully treating autoimmune neurological disorders, even when T cells seem to be the main effector cells. The paper summarizes basic aspects of B cell biology, discusses the roles of B cells in neurological autoimmunities, and highlights how the currently available or under development anti-B cell therapeutics exert their action in the wide spectrum and immunologically diverse neurological disorders. The efficacy of the various anti-B cell therapies and practical issues on induction and maintenance therapy is specifically detailed for the treatment of patients with multiple sclerosis, neuromyelitis-spectrum disorders, autoimmune encephalitis and hyperexcitability CNS disorders, autoimmune neuropathies, myasthenia gravis, and inflammatory myopathies. The success of anti-B cell therapies in inducing long-term remission in IgG4 neuroautoimmunities is also highlighted pointing out potential biomarkers for follow-up infusions.
Collapse
Affiliation(s)
- Panos Stathopoulos
- 1st Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece.
| |
Collapse
|
7
|
Co DO, Kwon JM. Autoimmune Encephalitis: Distinguishing Features and Specific Therapies. Crit Care Clin 2022; 38:393-412. [DOI: 10.1016/j.ccc.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
8
|
Lin KL. Diversity of clinical presentations in anti-N-methyl-D-aspartate receptor encephalitis - a long way to go. Pediatr Neonatol 2021; 62:345-346. [PMID: 34120864 DOI: 10.1016/j.pedneo.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| |
Collapse
|
9
|
Zografou C, Vakrakou AG, Stathopoulos P. Short- and Long-Lived Autoantibody-Secreting Cells in Autoimmune Neurological Disorders. Front Immunol 2021; 12:686466. [PMID: 34220839 PMCID: PMC8248361 DOI: 10.3389/fimmu.2021.686466] [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: 03/26/2021] [Accepted: 05/28/2021] [Indexed: 12/24/2022] Open
Abstract
As B cells differentiate into antibody-secreting cells (ASCs), short-lived plasmablasts (SLPBs) are produced by a primary extrafollicular response, followed by the generation of memory B cells and long-lived plasma cells (LLPCs) in germinal centers (GCs). Generation of IgG4 antibodies is T helper type 2 (Th2) and IL-4, -13, and -10-driven and can occur parallel to IgE, in response to chronic stimulation by allergens and helminths. Although IgG4 antibodies are non-crosslinking and have limited ability to mobilize complement and cellular cytotoxicity, when self-tolerance is lost, they can disrupt ligand-receptor binding and cause a wide range of autoimmune disorders including neurological autoimmunity. In myasthenia gravis with predominantly IgG4 autoantibodies against muscle-specific kinase (MuSK), it has been observed that one-time CD20+ B cell depletion with rituximab commonly leads to long-term remission and a marked reduction in autoantibody titer, pointing to a short-lived nature of autoantibody-secreting cells. This is also observed in other predominantly IgG4 autoantibody-mediated neurological disorders, such as chronic inflammatory demyelinating polyneuropathy and autoimmune encephalitis with autoantibodies against the Ranvier paranode and juxtaparanode, respectively, and extends beyond neurological autoimmunity as well. Although IgG1 autoantibody-mediated neurological disorders can also respond well to rituximab induction therapy in combination with an autoantibody titer drop, remission tends to be less long-lasting and cases where titers are refractory tend to occur more often than in IgG4 autoimmunity. Moreover, presence of GC-like structures in the thymus of myasthenic patients with predominantly IgG1 autoantibodies against the acetylcholine receptor and in ovarian teratomas of autoimmune encephalitis patients with predominantly IgG1 autoantibodies against the N‐methyl‐d‐aspartate receptor (NMDAR) confers increased the ability to generate LLPCs. Here, we review available information on the short-and long-lived nature of ASCs in IgG1 and IgG4 autoantibody-mediated neurological disorders and highlight common mechanisms as well as differences, all of which can inform therapeutic strategies and personalized medical approaches.
Collapse
Affiliation(s)
- C Zografou
- Institute of Neuropathology, University of Zurich, Zurich, Switzerland
| | - A G Vakrakou
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - P Stathopoulos
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
10
|
Hutchinson ML, Yeshokumar AK, Armangue T. Antibody-Mediated Encephalitis in Children: Focus on Diagnostic Clues and Acute Symptom Management. Semin Pediatr Neurol 2021; 37:100873. [PMID: 33892846 DOI: 10.1016/j.spen.2021.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 01/18/2023]
Abstract
Antibody-mediated encephalitis is a treatable cause of encephalitis that manifests over days to weeks as changes in behavior and cognition, seizures, movement disorders, and autonomic dysfunction. Patients with autoimmune encephalitis develop a variety of symptoms. As such, they require a multidisciplinary approach to care. In this review we summarize the clinical presentation and practical diagnostic approach to pediatric autoimmune encephalitis, review treatments of the autoimmune process, and discuss the management of the acute symptoms encountered in children.
Collapse
Affiliation(s)
| | - Anusha K Yeshokumar
- Departments of Neurology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain
| |
Collapse
|
11
|
Li X, Hou C, Wu WL, Liang H, Zheng K, Zhang Y, Zeng Y, Chen L, Zhu H, Tian Y, Gao Y, Peng B, Yang S, Wang X, Ning S, Liao Y, Lin H, Chen WX. Pediatric anti-N-methyl-d-aspartate receptor encephalitis in southern China: Analysis of 111 cases. J Neuroimmunol 2021; 352:577479. [PMID: 33486307 DOI: 10.1016/j.jneuroim.2021.577479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the clinical features of children diagnosed with anti-NMDAR encephalitis in southern China. METHODS Clinical data of children diagnosed with anti-NMDAR encephalitis from October 2014 to June 2020 from one national regional medical center were analyzed. Neurological disability was assessed by modified Rankin Scale (mRS) throughout the course of disease. RESULTS 111 children (M/F = 49/62; mean onset age = 6.8 y) with anti-NMDAR encephalitis were involved. Prodromal events occurred in 34.2% of patients with infectious events being the most common. Seizure was the most common initial symptom, though movement disorder served as the most common event throughout the course of disease. 9.9% of patients had overlapped with other neuronal autoantibodies. Electroencephalogram showed abnormalities with slow wave (100.0%), epileptic discharge (31.5%) and delta brush (8.1%) respectively. 41.4% of patients had abnormal brain MRI, with focal lesions being the most common. None patients had tumor. 80.9% of patients had good response to first line therapy (steroid plus immunoglobulin), while 14 patients accepted second-line therapy (Rituximab) and all had a good response. Boys were significantly more likely to need more course of steroid. 13.8% of patients relapsed. 2 male patients died. mRS score was significantly improved after treatment. 51.4% of patients had a full recovery and 81.7% had mRS score ≤ 2. The median mRS score of boys after treatment was higher than that of girls. Non-infectious prodromal event, past medical history, perivascular lesions in brain MRI, hospital stay, initial mRS score higher than 3, and RTX treatment were independent risk factors associated with poor prognosis, defined as mRS score > 2. CONCLUSION Of pediatric anti-NMDAR encephalitis in southern China: median onset age around 7 years; girls more common; boys might have poor outcome than girls; seizure or movement disorder respectively being most common onset or course symptom; a few overlapped with other neuronal autoantibodies; rare combined with tumor; most had a good response to immunotherapy and a good prognosis; relapse rate relatively high; fatality rate relatively low; some risk factors associated with poor prognosis.
Collapse
Affiliation(s)
- Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Wen-Lin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Huici Liang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Lianfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Sida Yang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Xiuying Wang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Shuyao Ning
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yinting Liao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Haisheng Lin
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China.
| |
Collapse
|
12
|
Hu S, Lan T, Bai R, Jiang S, Cai J, Ren L. HSV encephalitis triggered anti-NMDAR encephalitis: a case report. Neurol Sci 2021; 42:857-861. [PMID: 33420613 DOI: 10.1007/s10072-020-04785-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/28/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis (AE) is a common cause of nonviral infectious encephalitis, which can be triggered by herpes simplex virus infection. Previous studies have shown that approximately 27% of herpes simplex encephalitis (HSE) patients produce anti-NMDAR antibodies within 3 months. Immunotherapy is recommended in this situation, but some symptoms usually remain in the 1-year follow-up. CASE PRESENTATION A previously healthy 23-year-old Chinese young woman developed epileptic attack followed by psychiatric symptoms of confusion and irritation as well as cognitive deficits. Brain MRI showed hyperintense lesions of the right temporal lobe on DWI and T2 without contrast enhancement effects. Twenty-one days of acyclovir was administered based on the primary diagnosis of HSE. The anti-NMDAR antibody (IgG) was detected positively on day 11 after disease onset. She had improved cognitive function but suffered another grand mal epilepsy after the first course of intravenous immunoglobulin (IVIG) therapy combined with 1000 mg intravenous methylprednisolone. After discussion, another course of IVIG was started for 5 days. Her symptoms were well controlled with only mild cognitive deficits at the 1-year follow-up (mRS = 1). CONCLUSIONS Our case indicated that anti-NMDAR antibodies could develop earlier after HSE compared with previous data from adults. We suggested detecting AE antibodies simultaneously with each CSF analysis. Meanwhile, the second course of IVIG therapy was reasonable when symptoms were not controlled after the first course of IVIG combined with IV steroid treatment.
Collapse
Affiliation(s)
- Shiyu Hu
- Neurology Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Tao Lan
- Spine Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Runtao Bai
- Neurology Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Shirui Jiang
- Neurology Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
- The First Clinical Medical College of Anhui Medical University, Hefei, China
| | - Jingjing Cai
- Neurology Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China
| | - Lijie Ren
- Neurology Department of Shenzhen Second People's Hospital/First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, 518035, China.
| |
Collapse
|
13
|
Dou X, Li D, Wu Y, Wang Z, Yang L, Ma N, Wang D, Li X. Efficacy and Safety of Rituximab in Chinese Children With Refractory Anti-NMDAR Encephalitis. Front Neurol 2020; 11:606923. [PMID: 33381080 PMCID: PMC7767921 DOI: 10.3389/fneur.2020.606923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/24/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose: To assess the efficacy and safety of rituximab treatment as second-line immunotherapy in pediatric cases of anti-NMDA receptor (NMDAR) encephalitis. Methods: We retrospectively recruited 8 patients with anti-NMDAR encephalitis who were treated with rituximab as second-line immunotherapy. We evaluated the clinical features, laboratory examination results and treatment protocols of the Chinese children and defined good outcomes based on the modified Rankin scale (mRS) score (0-2) at the last follow-up. Results: A total of eight pediatric patients (median age 6.7 years; four female) with refractory anti-NMDAR encephalitis were recruited to the study. Rituximab was given after a median duration of disease of 57 days (range 50.5-113.75 days). The use of rituximab led to a significant reduction in the mRS and CD19+ B-cells compared to before rituximab infusion (P < 0.05). Five patients (62.5%) had a good outcome (mRS ≤ 2) including four patients (50%) who showed complete recovery (mRS = 0) at the last follow-up. Transient infusion adverse events were recorded in 2 patients (25%). Two patients (25%) had severe infectious adverse events (AEs) and two patients with grade 5 (death). None of the patients developed progressive multifocal leukoencephalopathy (PML). Conclusion: Our study provides evidence that rituximab can efficiently improve the clinical symptoms of anti-NMDAR encephalitis in children. However, due to the risk of adverse infections, rituximab should be restricted in pediatric patients with high rates of mortality and disability.
Collapse
Affiliation(s)
- Xiangjun Dou
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Dongjing Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Yan Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Zhijing Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Le Yang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Nan Ma
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Dong Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Xia Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| |
Collapse
|
14
|
Nepal G, Shing YK, Yadav JK, Rehrig JH, Ojha R, Huang DY, Gajurel BP. Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis. Acta Neurol Scand 2020; 142:449-459. [PMID: 32484900 DOI: 10.1111/ane.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE. METHODS This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment. RESULTS Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease. CONCLUSION Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.
Collapse
Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Yow K. Shing
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Jayant K. Yadav
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Jessica H. Rehrig
- University of New England College of Osteopathic Medicine Biddeford ME USA
| | - Rajeev Ojha
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Dong Y Huang
- Department of Neurology Shanghai East Hospital of Tongji University School of Medicine Shanghai China
| | - Bikram P. Gajurel
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| |
Collapse
|
15
|
Cafalli C, Amorim E, Silva F, Alves Junior JM, Anhesini MR, Bernardo WM. Autoimmune encephalitis (AIE). Rev Assoc Med Bras (1992) 2020; 66:1172-1178. [DOI: 10.1590/1806-9282.66.7.1172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
|
16
|
Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
Collapse
Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
| |
Collapse
|
17
|
Li XY, Shi ZH, Guan YL, Ji Y. Anti-N-methyl-D-aspartate-receptor antibody encephalitis combined with syphilis: A case report. World J Clin Cases 2020; 8:2603-2609. [PMID: 32607338 PMCID: PMC7322422 DOI: 10.12998/wjcc.v8.i12.2603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Xi-Yu Li
- Graduate School, Tianjin Medical College, Tianjin 300070, China
| | - Zhi-Hong Shi
- Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Dementia Institute, Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Ya-Lin Guan
- Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Dementia Institute, Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Yong Ji
- Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Dementia Institute, Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
- China National Clinical Research Center for Neurological Diseases, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| |
Collapse
|
18
|
Lin KL, Lin JJ. Neurocritical care for Anti-NMDA receptor encephalitis. Biomed J 2020; 43:251-258. [PMID: 32330674 PMCID: PMC7424095 DOI: 10.1016/j.bj.2020.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Jann-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
19
|
Guu TW, Tsai ST, Su KP. Autoimmune psychosis in Taiwan: A case report and review of literature. Brain Behav Immun Health 2020; 3:100055. [PMID: 34589840 PMCID: PMC8474284 DOI: 10.1016/j.bbih.2020.100055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 11/25/2022] Open
|
20
|
Bien CG, Bien CI. Autoimmune encephalitis in children and adolescents. Neurol Res Pract 2020; 2:4. [PMID: 33324910 PMCID: PMC7650092 DOI: 10.1186/s42466-019-0047-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background Autoimmune encephalitides with neural and glial antibodies have become an attractive field in neurology because the antibodies are syndrome-specific, explain the pathogenesis, indicate the likelihood of an underlying tumor, and often predict a good response to immunotherapy. The relevance and the management of antibody-associated encephalitides in the pediatric age group are to be discussed. Main body Subacutely evolving, complex neuropsychiatric conditions that are otherwise unexplained should raise the suspicion of autoimmune encephalitis. Determination of autoantibodies is the key diagnostic step. It is recommended to study cerebrospinal fluid and serum in parallel to yield highest diagnostic sensitivity and specificity. The most frequently found antibodies are those against the N-methyl-D-asparate receptor, an antigen on the neural cell surface. The second most frequent antibody is directed against glutamic acid decarboxylase 65 kDa, an intracellular protein, often found in chronic conditions with questionable inflammatory activity. Immunotherapy is the mainstay of treatment in autoimmune encephalitides. Steroids, apheresis and intravenous immunoglobulin are first-line interventions. Rituximab or cyclophosphamide are given as second-line treatments. Patients with surface antibodies usually respond well to immunotherapy whereas cases with antibodies against intracellular antigens most often do not. Conclusion With few exceptions, the experience in adult patients with autoimmune encephalitides can be applied to patients in the pediatric age range.
Collapse
Affiliation(s)
- C G Bien
- Epilepsy Center Bethel, Krankenhaus Mara, Maraweg 17-21, 33617 Bielefeld, Germany.,Laboratory Krone, Bad Salzuflen, Germany
| | - C I Bien
- Laboratory Krone, Bad Salzuflen, Germany
| |
Collapse
|