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Zhao X, Teng Y, Ni J, Li T, Shi J, Wei M. Systematic review: clinical characteristics of anti-N-methyl-D-aspartate receptor encephalitis. Front Hum Neurosci 2023; 17:1261638. [PMID: 38053649 PMCID: PMC10694196 DOI: 10.3389/fnhum.2023.1261638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/16/2023] [Indexed: 12/07/2023] Open
Abstract
Background The number of reported cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis has gradually increased since its discovery in 2007, while there are no uniform treatment guidelines. Objective To summarize the clinical characteristics of patients with anti-NMDAR encephalitis and to analyze the factors affecting the disease prognosis. Methods A systematic analysis of medical records was conducted, and PubMed, Embase, and Cochrane Library were searched from January 1, 2011, to December 31, 2021. Data were extracted, analyzed, and recorded in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results This study included 472 case reports. Most patients had prodromal symptoms of about 2 weeks, including psychiatric symptoms (53.2%), flu-like symptoms (51.5%), and seizures (23.9%), among others. Poor prognoses were associated with patients who had autonomic instability (p = 0.010), central hypoventilation (p = 0.014), and ICU support (p = 0.002). Patients with a higher age of onset were more likely to develop central hypoventilation (OR 1.024, CI 1.006-1.042, p = 0.009), cognitive impairment (OR 1.023, CI 1.009-1.037, p = 0.001), and memory impairment (OR 1.034, CI 1.017-1.050, p < 0.001), whereas patients with a lower age were more likely to have seizures (OR 0.979, CI 0.965-0.993, p = 0.003). In this study, 97.0% of patients received immunotherapy, with the most commonly used treatment regimen being intravenous methylprednisolone (IVGC) and intravenous immunoglobulin (IVIG). When compared with other treatment regimens, the IVGC+IVIG regimen (p < 0.001) resulted in better prognoses. Conclusion When encountering patients with fever, headache, and initial psychiatric symptoms of unknown etiology, clinicians should test their CSF for antibodies to distinguish autoimmune encephalitis. Patients with autonomic instability, central hypoventilation, and ICU support had poorer prognoses. Clinicians should be aware that older patients are more likely to develop central hypoventilation, cognitive impairment, and memory impairment, while younger patients are more likely to develop seizures. The IVGC+IVIG treatment regimen has better prognoses than others. This study includes case reports, which have obvious selection bias, and there are no unified standards to measure the severity of the disease. Therefore, in the future, larger samples and randomized controlled trials are needed to evaluate the efficacy of different treatment regimens.
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Affiliation(s)
- Xi Zhao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuou Teng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingnian Ni
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ting Li
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Shi
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mingqing Wei
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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2
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Vova JA, Howarth RA. Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children. Pediatr Clin North Am 2023; 70:429-444. [PMID: 37121635 DOI: 10.1016/j.pcl.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.
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Affiliation(s)
- Joshua A Vova
- Department of Physical Medicine and Rehabilitation, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road Northeast, Atlanta, GA 30342, USA; Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine.
| | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, 5461 Meridian Mark Road NE, Atlanta, GA 30342, USA; Department of Pediatrics, Division of Neurology, Emory University School of Medicine
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3
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Dou Q, Yang C, Tian M, Yuan X, Li R, Shu X. Clinical Characteristics and Prognosis of Antibody-Negative Autoimmune Encephalitis in Children: A Single-Center Retrospective Study. Pediatr Neurol 2022; 133:9-14. [PMID: 35716605 DOI: 10.1016/j.pediatrneurol.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/04/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a group of immune-mediated brain diseases. However, new diagnostic criteria for AE in children indicate that partial pediatric patients with AE may be diagnosed without evidence of positive autoantibodies. Therefore, the clinical characteristics and prognosis of children with antibody-negative but probable AE require further investigation. METHODS Forty-one children with AE admitted to our hospital from April 2014 to January 2021 were retrospectively enrolled in this study. Children were divided into two groups according to positive or negative antibody tests. Clinical characteristics, cerebrospinal fluid, video electroencephalography, brain magnetic resonance imaging, and prognosis were analyzed, and the correlation between modified Rankin scale (mRS) and neutrophil-to-lymphocyte ratio (NLR) was examined. RESULTS Of 41 children, 16 cases tested positive for autoantibodies. The main features were psychiatric symptoms, cognitive disturbances, speech disturbances, movement disorders, and seizures. All the children were given a combination of intravenous methylprednisolone pulses with intravenous immunoglobulin therapy; 26 cases (63%) had a good outcome, and 15 cases (37%) had a poor outcome. Antibody-positive and antibody-negative but probable AE were analyzed by univariate analysis and showed lower lymphocyte counts and higher NLR and mRS scores in the antibody-negative group (P < 0.05). The Spearman rank correlation analysis showed a positive correlation between NLR level and mRS scores (P < 0.05). CONCLUSIONS Antibody-negative but possible AE is frequent in children who may have a more severe neurological impairment and higher NLR than antibody-positive AE. Aggressive immunotherapy in antibody-negative AE is essential to achieve a good prognosis.
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Affiliation(s)
- Qingyang Dou
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China; Department of Pediatrics, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Changjian Yang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Maoqiang Tian
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Xing Yuan
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Renke Li
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Xiaomei Shu
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China.
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4
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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5
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Feng J, Yang M, Cui D, Huang Z, Ji T, Lian Y. Recurrence of Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Cohort Study in Central China. Front Neurol 2022; 13:832634. [PMID: 35356456 PMCID: PMC8959942 DOI: 10.3389/fneur.2022.832634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/01/2022] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate factors that could impact or predict the probability of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis recurrence in central China. Methods From November 2014 to October 2020, observational data of anti-NMDAR encephalitis inpatients in our institution were collected and analyzed prospectively. The demographics, clinical characteristics, tumor status, lesion locations on MRI and immunotherapies, etc. had entered into a Cox regression model for the identification of the factors associated with relapse-free survival. Results We enrolled 113 patients in a row (median age: 28 years, range: 1-61 years). The gender distribution was not statistically significant (p = 0.158), with 49 people (43.4%) being female. The median follow-up time was 16 (4-77) months. Among them, 16.8% of patients relapsed. The average interval between recurrences was 8 months (range 3-54 mo). The severity of the initial relapse was less severe than it had been at the start. The first relapse had considerably fewer symptoms (median 2, range 1-6) than the first episode (median 4, range 1-8, p = 0.005). The mRS at first relapse (median 3, mean 2.84, range 1-5) had been significantly lower than that at onset (median 4, mean 3.89, range 3-5, p = 0.004). The length of hospitalization at first relapse (median 17 days, range 5-46) was significantly shorter than the first episode (median 35 days, range 14-102, p = 0.002). In the survival analysis, the risk of recurrence was significantly higher for patients with a brainstem lesion (HR: 4.112, 95% CI: 1.205-14.030; p = 0.024) or ≥3 abnormal sites (HR: 2.926, 95% CI: 1.085-7.896; p = 0.034) on brain MRI at the first episode. There was no significant difference in neurological outcomes between the recurrent and monophasic groups at the most recent follow-up (mRS 0-2 in 17/19 vs. 86/94; p = 0.674). Conclusions Anti-NMDAR encephalitis can recur in around one out of every six cases, and symptoms are generally milder than when it first appears. Recurrence is not related to the severity in the acute phase or the prognosis at follow-up. Patients with ≥3 abnormal sites on MRI or lesions located in the brainstem at onset must be alert to the possibility of recurrence.
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Affiliation(s)
| | | | | | | | | | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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6
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Wright MA, Trandafir CC, Nelson GR, Hersh AO, Inman CJ, Zielinski BA. Diagnosis and Management of Suspected Pediatric Autoimmune Encephalitis: A Comprehensive, Multidisciplinary Approach and Review of Literature. J Child Neurol 2022; 37:303-313. [PMID: 34927485 DOI: 10.1177/08830738211064673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Autoimmune encephalitis is an increasingly recognized entity in children. When treated promptly, favorable outcomes are seen in a majority of pediatric patients. However, recognition of autoimmune encephalitis in young patients is challenging. Once autoimmune encephalitis is suspected, additional difficulties exist regarding timing of treatment initiation and duration of treatment, as evidence to guide management of these patients is emerging. Here, we review available literature regarding pediatric autoimmune encephalitis and present our institution's comprehensive approach to the evaluation and management of the disease. These guidelines were developed through an iterative process involving both pediatric neurologists and rheumatologists.
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Affiliation(s)
- Melissa A Wright
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Cristina C Trandafir
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Gary R Nelson
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Aimee O Hersh
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - C J Inman
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Brandon A Zielinski
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Department of Neurology, 14434University of Utah, Salt Lake City, UT, USA
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7
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Dou X, Li D, Wu F, Wang Z, Niu M, Wu Y, Deng T, Wang D, Li X. The clinical features, treatment and outcomes of 33 children from Northwestern China with Anti-N-methyl-D-aspartate receptor encephalitis. Neurol Res 2021; 44:429-438. [PMID: 34806564 DOI: 10.1080/01616412.2021.2000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES We analyzed the clinical features and outcomes of children with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis in Northwestern China. METHODS We retrospectively recruited 33 pediatric patients with anti-NMDAR encephalitis in Northwestern China from December 2013 to April 2020. The demographics, clinical features, treatments, and outcomes were reviewed. RESULTS 33 patients with anti-NMDAR encephalitis were enrolled in this study (a median age of 6.8 years, 20 females and 13 males). The initial symptoms included seizures (42.4%), psychiatric symptoms (39.4%), speech dysfunction (12.1%), and paralysis (6.1%). During the course of the disease, 31 patients (93.9%) presented with psychiatric symptoms, 29 patients (87.9%) presented with speech dysfunction, 25 patients (75.8%) presented with movement disorders and 24 patients (72.7%) presented with sleep disorders followed by seizures, consciousness disturbance, autonomic nervous dysfunction, paralysis, and hypoventilation. 12 patients (36.4%) had abnormal cerebrospinal fluid (CSF) findings, 10 patients (30.3%) exhibited abnormal brain magnetic resonance imaging (MRI) results, and 29 patients (87.9%) showed abnormal Electroencephalography (EEG) findings. None of the patients had tumors. All patients received first-line immunotherapy and 8 patients both received first and second-line immunotherapy. 30 of the 33 patients achieved good outcomes (score on the modified Rankin Scale [mRS] of 0-2), whilst the other 3 patients had poor outcomes (mRS score of 3-6). CONCLUSIONS Patients with higher CSF anti-NMDAR body titer were more likely to develop sleep disorders, consciousness disturbances and more severe disease states.
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Affiliation(s)
- Xiangjun Dou
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Dongjing Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Fang Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Zhijing Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Mengmeng Niu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - You Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Ting Deng
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Dong Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Xia Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
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8
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Nosadini M, Eyre M, Molteni E, Thomas T, Irani SR, Dalmau J, Dale RC, Lim M, Anlar B, Armangue T, Benseler S, Cellucci T, Deiva K, Gallentine W, Gombolay G, Gorman MP, Hacohen Y, Jiang Y, Lim BC, Muscal E, Ndondo A, Neuteboom R, Rostásy K, Sakuma H, Sartori S, Sharma S, Tenembaum SN, Van Mater HA, Wells E, Wickstrom R, Yeshokumar AK. Use and Safety of Immunotherapeutic Management of N-Methyl-d-Aspartate Receptor Antibody Encephalitis: A Meta-analysis. JAMA Neurol 2021; 78:1333-1344. [PMID: 34542573 PMCID: PMC8453367 DOI: 10.1001/jamaneurol.2021.3188] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Question What are the most effective treatments for N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis? Findings In this meta-analysis of individual patient data including 1550 cases, treatment factors at first event that were significantly associated with good functional outcome 12 months from disease onset included first-line treatment with therapeutic apheresis alone, corticosteroids in combination with intravenous immunoglobulin (IVIG), or corticosteroids in combination with IVIG and therapeutic apheresis, while lack of immunotherapy within 30 days of disease onset was significantly associated with poor outcome. Rituximab and long-term IVIG use were significantly associated with nonrelapsing disease course. Meaning Separate treatment factors are associated with functional outcomes and relapsing disease biology in those with NMDAR antibody encephalitis. Importance Overall, immunotherapy has been shown to improve outcomes and reduce relapses in individuals with N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis (NMDARE); however, the superiority of specific treatments and combinations remains unclear. Objective To map the use and safety of immunotherapies in individuals with NMDARE, identify early predictors of poor functional outcome and relapse, evaluate changes in immunotherapy use and disease outcome over the 14 years since first reports of NMDARE, and assess the Anti-NMDAR Encephalitis One-Year Functional Status (NEOS) score. Data Sources Systematic search in PubMed from inception to January 1, 2019. Study Selection Published articles including patients with NMDARE with positive NMDAR antibodies and available individual immunotherapy data. Data Extraction and Synthesis Individual patient data on immunotherapies, clinical characteristics at presentation, disease course, and final functional outcome (modified Rankin Scale [mRS] score) were entered into multivariable logistic regression models. Main Outcomes and Measures The planned study outcomes were functional outcome at 12 months from disease onset (good, mRS score of 0 to 2; poor, mRS score greater than 2) and monophasic course (absence of relapse at 24 months or later from onset). Results Data from 1550 patients from 652 articles were evaluated. Of these, 1105 of 1508 (73.3%) were female and 707 of 1526 (46.3%) were 18 years or younger at disease onset. Factors at first event that were significantly associated with good functional outcome included adolescent age and first-line treatment with therapeutic apheresis, corticosteroids plus intravenous immunoglobulin (IVIG), or corticosteroids plus IVIG plus therapeutic apheresis. Factors significantly associated with poor functional outcome were age younger than 2 years or age of 65 years or older at onset, intensive care unit admission, extreme delta brush pattern on electroencephalography, lack of immunotherapy within the first 30 days of onset, and maintenance IVIG use for 6 months or more. Factors significantly associated with nonrelapsing disease were rituximab use or maintenance IVIG use for 6 months or more. Adolescent age at onset was significantly associated with relapsing disease. Rituximab use increased from 13.5% (52 of 384; 2007 to 2013) to 28.3% (311 of 1100; 2013 to 2019) (P < .001), concurrent with a falling relapse rate over the same period (22% [12 of 55] in 2008 and earlier; 10.9% [35 of 322] in 2017 and later; P = .006). Modified NEOS score (including 4 of 5 original NEOS items) was associated with probability of poor functional status at 1 year (20.1% [40 of 199] for a score of 0 to 1 points; 43.8% [77 of 176] for a score of 3 to 4 points; P = .05). Conclusions and Relevance Factors influencing functional outcomes and relapse are different and need to be considered independently in development of evidence-based optimal management guidelines of patients with NMDARE.
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Affiliation(s)
- Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza," Padova, Italy
| | - Michael Eyre
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.,Centre for Medical Engineering, King's College London, London, United Kingdom
| | - Terrence Thomas
- Department of Paediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Department of Neurology, University of Pennsylvania, Philadelphia.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Russell C Dale
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Women and Children's Health, School of Life Course Sciences (SoLCS), King's College London, London, United Kingdom
| | | | | | - Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Susanne Benseler
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Saclay, Bicêtre Hospital, Paris, France.,French Reference Network of Rare Inflammatory Brain and Spinal Diseases, Paris, France.,European Reference Network-RITA, Paris, France
| | - William Gallentine
- Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Grace Gombolay
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark P Gorman
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yael Hacohen
- Queen Square MS Centre, UCL Institute of Neurology, University College London, London, United Kingdom.,Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Yuwu Jiang
- Peking University First Hospital, Beijing, China
| | - Byung Chan Lim
- Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eyal Muscal
- Section Rheumatology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Alvin Ndondo
- Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Faculty of Health Sciences, University of Cape Town Neuroscience Institute, Cape Town, South Africa
| | | | - Kevin Rostásy
- Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Hiroshi Sakuma
- Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Stefano Sartori
- Neuroimmunology Group, Paediatric Research Institute "Città della Speranza," Padova, Italy.,University Hospital of Padova, Padova, Italy
| | - Suvasini Sharma
- Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
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9
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Tarantino S, Averna R, Ruscitto C, Ursitti F, Ferilli MAN, Moavero R, Papetti L, Proietti Checchi M, Sforza G, Balestri M, Grimaldi Capitello T, Vigevano F, Vicari S, Valeriani M. Neuropsychological Sequelae, Quality of Life and Adaptive Behavior in Children and Adolescents with Anti-NMDAR Encephalitis: A Narrative Review. Brain Sci 2021; 11:brainsci11111387. [PMID: 34827386 PMCID: PMC8615663 DOI: 10.3390/brainsci11111387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune illness characterized by a constellation of often severe, but treatable, psychiatric and neurological symptoms. Whereas symptoms such as psychosis and bizarre and abnormal motor behavior are common in adults, pediatric patients typically present with behavioral changes, irritability and sleep dysfunction. The recovery phase is usually slow and may be associated with longstanding adaptive, behavioral and neuropsychological problems. Very few studies explored the cognitive and adaptive sequelae in children with anti-NMDAR encephalitis. The present review article suggests that, although most children and adolescents return to their daily life and previous activities, they may have a low quality of life and show neuropsychological sequelae involving language, memory, especially verbal memory, and attentional resources, even after several months from the hospital discharge. In particular, the available results reveal difficulties in cognitive skills involving executive functions. This impairment is considered the “core” of the cognitive profile of young patients with anti-NMDAR encephalitis. On the other hand, some cognitive skills, such as general intelligence, show good overall recovery over time. Additional neuropsychological research evaluating larger samples, more homogenous methods and longitudinal studies is required.
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Affiliation(s)
- Samuela Tarantino
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
- Correspondence:
| | - Roberto Averna
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Claudia Ruscitto
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
| | - Fabiana Ursitti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Michela Ada Noris Ferilli
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Laura Papetti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Proietti Checchi
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Giorgia Sforza
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Balestri
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Teresa Grimaldi Capitello
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Federico Vigevano
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Stefano Vicari
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Massimiliano Valeriani
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
- Center for Sensory-Motor Interaction, Denmark Neurology Unit, Aalborg University, 9100 Aalborg, Denmark
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Datta AK, Pandit A, Biswas S, Biswas A, Roy BK, Gangopaddhyay G. Spectrum of Anti-NMDA Receptor Antibody Encephalitis: Clinical Profile, Management and Outcomes. Ann Indian Acad Neurol 2021; 24:383-389. [PMID: 34447002 PMCID: PMC8370154 DOI: 10.4103/aian.aian_817_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/02/2020] [Accepted: 10/14/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Anti-N-methyl D-aspartate receptor (anti NMDAR) antibody encephalitis is an immune-mediated entity characterised by a constellation of neuro-psychiatric symptoms. Objective: To describe clinical profile and treatment outcomes of patients with anti NMDAR antibody encephalitis. Settings and Design: Subjects were selected by screening for all patients satisfying Graus et al.'s criteria for probable anti NMDAR antibody encephalitis, admitted in neurology department of a tertiary care centre in Eastern India. Materials and Methods: A prospective, longitudinal study was conducted by identifying 25 patients with anti NMDAR antibodies in CSF and or serum, between September 2018 to February 2020. Statistical Analysis: Chi square test was used to compare variables. Results: Out of 98 patients screened, 25 subjects (14 females: 11 male) were positive for anti NMDAR autoantibodies, with a mean age of 17 years. 13 subjects belonged to paediatric age group. Most common presenting feature was memory/learning deficit (88%) followed by behavioural abnormalities (84%) and seizures (68%). 11 patients (44%) patients needed escalation to second line therapy, rituximab. Seven (28%) and twelve (48%) patients underwent complete (mRS 0-1) and partial recovery (mRS 2-3) respectively, while 4 (16%) became disabled (mRS 4-5). Mortality was 8%. Paediatric population had a better outcome in terms of disability (p = 0.043). Conclusion: Anti NMDAR-Ab encephalitis is the most common cause of antibody positive autoimmune encephalitis worldwide. There are important clinical markers and investigational profiles which carry prognostic significance.
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Affiliation(s)
- Amlan Kusum Datta
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Samar Biswas
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Atanu Biswas
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Biman Kanti Roy
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Goutam Gangopaddhyay
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
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Jiang H, Ye H, Wang Y, Li Y, Wang Y, Li X. Anti-N-Methyl-D-Aspartate Receptor Encephalitis Associated with Ovarian Teratoma in South China-Clinical Features, Treatment, Immunopathology, and Surgical Outcomes of 21 Cases. Dis Markers 2021; 2021:9990382. [PMID: 34093900 DOI: 10.1155/2021/9990382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/08/2021] [Indexed: 11/24/2022]
Abstract
Objective To study the clinical characteristics and surgical outcomes of anti-NMDAR encephalitis and the immunopathology of associated teratomas. Methods Twenty-one patients were enrolled in this retrospective study, who were diagnosed with anti-NMDAR encephalitis with ovarian teratoma and admitted to two tertiary hospitals in South China from July 2014 to December 2019. The clinical data of patients were reviewed. Comparisons were made between the patients with different outcomes after surgery. Immunohistochemical analyses of associated ovarian teratomas were performed. Results The mean age of the patients was 24.33 ± 5.12 years. The peak seasons of disease onset were autumn and winter (30.61% and 32.65%). The symptoms could be divided into 8 categories, including psychiatric abnormalities, seizures, movement dysfunction, consciousness disorders, autonomic dysregulation, speech disturbance, central hypoventilation, and memory deficits. All patients developed four or more categories of symptoms within the first four weeks. Twelve patients (57.1%) had a maximum mRS of 5, and 11 patients (52.4%) were admitted to ICU. Twenty patients received surgery, and only 3 patients were diagnosed pathologically with immature ovarian teratomas, while the other 17 patients had mature ovarian teratomas. After surgery, 17 patients (85.0%) got clinical improvement. The central hypoventilation symptom and mature ovarian teratomas were associated with surgical outcome. Immunohistochemical analysis revealed that there were NMDAR-positive neural tissues in all 8 teratomas and in which 3 cases also contained large numbers of NMDAR-positive sebaceous glands and squamous epithelial tissues. Conclusion The disease is of high prevalence in autumn and winter. The central hypoventilation symptom and mature ovarian teratomas were associated with surgical outcome. NMDAR-positive neural tissue is not the only etiological factor of encephalitis. We speculate that encephalitis development in some patients may result from NMDAR expression in sebaceous glands and squamous epithelial tissues.
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Vova JA. A narrative review of pharmacologic approaches to symptom management of pediatric patients diagnosed with anti-NMDA receptor encephalitis. J Pediatr Rehabil Med 2021; 14:333-343. [PMID: 34486993 DOI: 10.3233/prm-200677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Anti-N-Methyl-D-Aspartate Receptor Encephalitis (ANMDARE) is one of the most common autoimmune encephalitis in the pediatric population. Patients with ANMDARE initially present with a prodrome of neuropsychiatric symptoms followed by progressively worsening seizures, agitation, and movement disorders. Complications can include problems such as aggression, insomnia, catatonia, and autonomic instability. Due to the complexity of this disease process, symptom management can be complex and may lead to significant polypharmacy. The goal of this review is to educate clinicians about the challenges of managing this disorder and providing guidance in symptom management.
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Affiliation(s)
- Joshua A Vova
- Department of Physiatry, Children's Healthcare of Atlanta, Johnson Ferry Rd NE. Atlanta, GA, USA
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Alvarez G, Krentzel A, Vova J, Blackwell L, Howarth R. Pharmacologic Treatment and Early Rehabilitation Outcomes in Pediatric Patients With Anti-NMDA Receptor Encephalitis. Arch Phys Med Rehabil 2021; 102:406-12. [PMID: 33058859 DOI: 10.1016/j.apmr.2020.09.381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/31/2020] [Accepted: 09/08/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe the immunotherapy and pharmacologic treatments administered to pediatric patients with N-methyl-D-aspartate receptor encephalitis (NMDARE) during inpatient rehabilitation as well as to examine clinical and demographic variables associated with early functional outcomes. DESIGN Retrospective chart review and post hoc analysis. SETTING Pediatric inpatient rehabilitation unit. PARTICIPANTS Pediatric patients (N=26; mean age, 10.79±5.17y) admitted to an inpatient rehabilitation unit with a confirmed diagnosis of NMDARE. INTERVENTIONS Inpatient rehabilitation; pharmacologic treatments. MAIN OUTCOME MEASURE FIM for Children (WeeFIM) Developmental Functional Quotient (DFQ). RESULTS All patients received first-line immunotherapies to treat NMDARE, and 69% also received second-line immunotherapies. Patients were prescribed an average of 8 medications for symptom management (range, 3-15 per patient), most often for the treatment of agitation (100%), psychiatric symptoms (92%), and seizures (65%). Sixty-five percent of patients demonstrated an improvement in Total WeeFIM DFQ over the course of inpatient rehabilitation, with 35% demonstrating limited to no change in Total WeeFIM DFQ ("unfavorable early outcome"). Those with unfavorable early outcome were significantly younger than those showing more favorable outcome. Pharmacologic treatment for seizures, movement disorders, and decreased arousal or level of consciousness were each associated with unfavorable early outcome independent of age differences. CONCLUSION Findings highlight the symptomatic heterogeneity and polypharmacy involved in the care and treatment of patients with NMDARE, with patients receiving a variety of immunotherapies and medications for symptom management. The presence of (and treatment for) seizures, movement disorders, and deteriorated neurologic status may each be associated with poor early outcomes in this population. Further investigation is needed to better classify presentations and treatments for this disease and to determine how differences are associated with long-term outcomes.
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Cordani R, Micalizzi C, Giacomini T, Gastaldi M, Franciotta D, Fioredda F, Buratti S, Morana G, Pirlo D, Renna S, Castagnola E, Risso M, Lanteri P, Vari MS, Mancardi MM. Bortezomib-Responsive Refractory Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Pediatr Neurol 2020; 103:61-64. [PMID: 31759783 DOI: 10.1016/j.pediatrneurol.2019.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/23/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor encephalitis is a central nervous system inflammatory autoimmune disease affecting adults and children. The use of first- and second-line immunotherapies is supported. Recent reports suggest the efficacy of bortezomib in severe anti-N-methyl-d-aspartate encephalitis in adult patients not responsive to second-line treatment; there are no data about pediatric patients. PATIENT DESCRIPTION We describe an eight-year-old child with anti-N-methyl-d-aspartate encephalitis not responsive to first- and second-line treatments who experienced marked clinical improvement after bortezomib administration. DISCUSSION Bortezomib is a selective and reversible inhibitor of the 26S proteasome, which is used to treat oncologic and rare autoimmune disorders in pediatric patients. As observed in adult patients, bortezomib administration induced anti-N-methyl-d-aspartate antibody titer decline and clinical improvement with an acceptable risk profile. CONCLUSION This is the first report of the use of bortezomib in children with anti-N-methyl-d-aspartate encephalitis; it could be a useful therapeutic option in children with refractory anti-N-methyl-d-aspartate encephalitis.
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Affiliation(s)
- Ramona Cordani
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | | | - Thea Giacomini
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Giovanni Morana
- Unit of Neuroradiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Daniela Pirlo
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Salvatore Renna
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Elio Castagnola
- Unit of Infectious Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Marco Risso
- Unit of Immunology and Transfusional Medicine, IRCCS Giannina Gaslini, Genova, Italy
| | - Paola Lanteri
- Unit of Neurophysiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Stella Vari
- Unit of Pediatric Neurology and Neurogenerative Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Margherita Mancardi
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genova, Italy.
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Zhang L, Lu Y, Xu L, Liu L, Wu X, Zhang Y, Zhu G, Hong Z. Anti-N-methyl-D-aspartate receptor encephalitis with accompanying ovarian teratoma in female patients from East China: Clinical features, treatment, and prognostic outcomes. Seizure 2019; 75:55-62. [PMID: 31874360 DOI: 10.1016/j.seizure.2019.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The association between anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR encephalitis) and teratoma is formally recognized. This study compared the clinical features, treatments and outcomes between female patients with or without accompanying teratomas and determined the potential influences of coexisting teratomas. METHOD Fifty-six female patients diagnosed with anti-NMDAR encephalitis were enrolled in two major tertiary hospitals in East China from January 2013 through March 2018 and were grouped as patients with or without teratoma. The clinical features were reviewed, and follow-up studies were performed. Comparisons were made between the two groups. RESULTS Patients with teratoma reported fewer viral prodromes (p = 0.0085) and stronger positive intensity of anti-NMDAR antibodies in cerebrospinal fluid (CSF) (p = 0.0368), while nontumor patients tended to demonstrate lymphocytic pleocytosis in CSF (p = 0.0306). Seizure types varied between individuals, with complex partial seizures more common in teratoma patients (p = 0.0105). Nontumor patients frequently required combinations of first-line and second-line immunotherapy (p = 0.0014), which may be attributed to higher mRS scores at admission (p = 0.0300). Also, they had higher mean mRS scores since the 12-month follow-up and greater probability of relapse than did patients with teratomas (p = 0.0286). CONCLUSIONS Symptomatology and auxiliary findings indicate that ovarian teratoma may be the immunologic trigger for anti-NMDAR encephalitis patients, while viral infection is likely to play a major part in pathogenesis for those without any detectable tumor. Overall, anti-NMDAR encephalitis patients with teratomas present with milder neurological symptoms and have better long-term outcomes after tumor removal.
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Affiliation(s)
- Lu Zhang
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Yao Lu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lan Xu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lu Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Xunyi Wu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China.
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
| | - Guoxing Zhu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhen Hong
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
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Nosadini M, Toldo I, Tascini B, Bien CG, Parmeggiani L, De Gaspari P, Zuliani L, Sartori S. LGI1 and CASPR2 autoimmunity in children: Systematic literature review and report of a young girl with Morvan syndrome. J Neuroimmunol 2019; 335:577008. [DOI: 10.1016/j.jneuroim.2019.577008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
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18
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Nosadini M, Granata T, Matricardi S, Freri E, Ragona F, Papetti L, Suppiej A, Valeriani M, Sartori S. Relapse risk factors in anti-N-methyl-D-aspartate receptor encephalitis. Dev Med Child Neurol 2019; 61:1101-1107. [PMID: 31175679 DOI: 10.1111/dmcn.14267] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2019] [Indexed: 01/16/2023]
Abstract
AIM To identify factors that may predict and affect the risk of relapse in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHOD This was a retrospective study of an Italian cohort of patients with paediatric (≤18y) onset anti-NMDAR encephalitis. RESULTS Of the 62 children included (39 females; median age at onset 9y 10mo, range 1y 2mo-18y; onset between 2005 and 2018), 21 per cent relapsed (median two total events per relapsing patient, range 2-4). Time to first relapse was median 31.5 months (range 7-89mo). Severity at first relapse was lower than onset (median modified Rankin Scale [mRS] 3, range 2-4, vs median mRS 5, range 3-5; admission to intensive care unit: 0/10 vs 3/10). At the survival analysis, the risk of relapsing was significantly lower in patients who received three or more different immune therapies at first disease event (hazard ratio 0.208, 95% confidence interval 0.046-0.941; p=0.042). Neurological outcome at follow-up did not differ significantly between patients with relapsing and monophasic disease (mRS 0-1 in 39/49 vs 12/13; p=0.431), although follow-up duration was significantly longer in relapsing (median 84mo, range 14-137mo) than in monophasic patients (median 32mo, range 4-108mo; p=0.002). INTERPRETATION Relapses may occur in about one-fifth of children with anti-NMDAR encephalitis, are generally milder than at onset, and may span over a long period, although they do not seem to be associated with severity in the acute phase or with outcome at follow-up. Aggressive immune therapy at onset may reduce risk of relapse. WHAT THIS PAPER ADDS Relapses of anti-N-methyl-D-aspartate receptor encephalitis may span over a long period. Relapses were not associated with severity in the acute phase or outcome at follow-up. Aggressive immune therapy at onset appears to decrease risk of relapse.
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Affiliation(s)
- Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute 'Città della Speranza', Padua, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Laura Papetti
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Agnese Suppiej
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Massimiliano Valeriani
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute 'Città della Speranza', Padua, Italy
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Joubert B, Dalmau J. The role of infections in autoimmune encephalitides. Rev Neurol (Paris) 2019; 175:420-6. [DOI: 10.1016/j.neurol.2019.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/06/2019] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
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20
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Zhang M, Li W, Zhou S, Zhou Y, Yang H, Yu L, Wang J, Wang Y, Zhang L. Clinical Features, Treatment, and Outcomes Among Chinese Children With Anti-methyl-D-aspartate Receptor (Anti-NMDAR) Encephalitis. Front Neurol 2019; 10:596. [PMID: 31244759 PMCID: PMC6562280 DOI: 10.3389/fneur.2019.00596] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is the most common form of autoimmune encephalitis in pediatric patients. In this study, we aimed to investigate the clinical features and long-term outcomes of pediatric patients with anti-NMDAR encephalitis in China. Methods: We conducted a retrospective study of children (age range: 0–18 years) with anti-NMDAR encephalitis treated at Children's Hospital of Fudan University between July 2015 and November 2018. Demographic characteristics, clinical features, treatment, and outcomes were reviewed. Results: Thirty-four patients with anti-NMDAR encephalitis were enrolled (age range: 5 months to 14 years; median age: 7 years; female: 18). The median follow- up duration was 20 months (range: 6–39 months). Eighteen (52.9%) patients initially presented with seizures and 10 (29.4%) with abnormal (psychiatric) behaviors or cognitive dysfunction. Thirty (88.2%) patients exhibited more than two symptoms during the disease course. No neoplasms were detected. Twelve (35.2%) patients had abnormal cerebrospinal fluid (CSF) findings, including leukocytosis, and increased protein concentration. Eighteen (52.9%) patients exhibited normal brain MRI findings. Electroencephalography revealed abnormal background activity in 27 (79.4%) patients, and epileptiform discharges in 16 (47.0%) patients prior to immunotherapy. All patients received first-line immunotherapy, with 30 (88.2%) and four (11.8%) patients achieving good (Modified Rankin Scale [mRS] score of 0–2) and poor outcomes (mRS score of 3–5), respectively. Initial mRS scores differed significantly between the good and poor outcome groups. Fourteen out of 18 patients (77.7%) with seizures accepted anti-epileptic drug (AED) administration, and seizure freedom was achieved in 12 out of 14 (85.7%) patients at the last follow-up. Ten of these 12 (83.3%) patients withdrew from AED treatment within 1 year. Conclusions: Most patients achieved seizure freedom, so long-term use of AEDs may not be necessary for pediatric patients with anti-NMDAR encephalitis. Among our patients, 83.3% were sensitive to first-line immunotherapy and achieved good outcomes. Higher mRS scores before immunotherapy predicted poor outcomes, highlighting the need for a comprehensive assessment of patients with anti-NMDAR encephalitis.
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Affiliation(s)
- Min Zhang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Haowei Yang
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, China
| | - Lifei Yu
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Ji Wang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Linmei Zhang
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
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Zuliani L, Nosadini M, Gastaldi M, Spatola M, Iorio R, Zoccarato M, Mariotto S, De Gaspari P, Perini F, Ferrari S, Evoli A, Sartori S, Franciotta D, Giometto B. Management of antibody-mediated autoimmune encephalitis in adults and children: literature review and consensus-based practical recommendations. Neurol Sci 2019; 40:2017-30. [PMID: 31161339 DOI: 10.1007/s10072-019-03930-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 05/09/2019] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis associated with antibodies against neuronal surface targets (NSAE) are rare but still underrecognized conditions that affect adult and pediatric patients. Clinical guidelines have recently been published with the aim of providing diagnostic clues regardless of antibody status. These syndromes are potentially treatable but the choice of treatment and its timing, as well as differential diagnoses, long-term management, and clinical and paraclinical follow-up, remain major challenges. In the absence of evidence-based guidelines, management of these conditions is commonly based on single-center expertise.Taking into account different published expert recommendations in addition to the multicenter experience of the Italian Working Group on Autoimmune Encephalitis, both widely accepted and critical aspects of diagnosis, management and particularly of immunotherapy for NSAE have been reviewed and are discussed.Finally, we provide consensus-based practical advice for managing hospitalization and follow-up of patients with NSAE.
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Gurrera RJ. Recognizing psychiatric presentations of anti-NMDA receptor encephalitis in children and adolescents: A synthesis of published reports. Psychiatry Clin Neurosci 2019; 73:262-268. [PMID: 30653785 DOI: 10.1111/pcn.12821] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 12/27/2022]
Abstract
AIM The aim of this study was to improve early recognition of anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDArE) in children and adolescents by identifying characteristic temporal patterns of clinical features in patients likely to be referred for psychiatric evaluation. In this form of autoimmune encephalitis, NMDAr hypofunction is caused by autoantibodies to receptor surface components. Clinical outcomes following prompt immunotherapy are usually good, but delayed treatment often results in a protracted course with significant residual disability or death. Anti-NMDArE frequently mimics psychiatric disorders, so most patients are referred initially to a psychiatrist and treated for days or weeks before being correctly diagnosed. METHODS A systematic search of PubMed and EMBASE electronic databases identified all published reports of antibody-confirmed anti-NMDArE associated with psychiatric symptoms in patients <19 years old. Redundant reports were eliminated manually. For each patient, the order in which each feature was first observed was ranked relative to others. Median temporal ranks were used to compare the sequencing of individual features and major symptom domains. RESULTS One hundred and sixty seven cases (121 females) met the inclusion criteria. The most common features were dyskinesias (77.8%), seizures (72.5%), mutism or staring (40.7%), insomnia (39.5%), language dysfunction (36.5%), fever (31.1%), disorientation/confusion (28.7%), reduced arousal (28.1%), and memory disturbance (26.9%). The configuration and temporal sequencing of features were highly variable between individuals. CONCLUSION Clinicians need to suspect this disorder: if new behavioral symptoms arise in the context of a recent viral prodrome; if they are accompanied by dyskinesias, seizures or insomnia; or if psychiatric symptoms are unusual (e.g., non-verbal auditory hallucinations).
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Affiliation(s)
- Ronald J Gurrera
- Mental Health Service, VA Boston Healthcare System, Boston, USA.,Harvard Medical School Department of Psychiatry, Boston, USA
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Nosadini M, Mohammad SS, Toldo I, Sartori S, Dale RC. Mycophenolate mofetil, azathioprine and methotrexate usage in paediatric anti-NMDAR encephalitis: A systematic literature review. Eur J Paediatr Neurol 2019; 23:7-18. [PMID: 30318435 DOI: 10.1016/j.ejpn.2018.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/12/2018] [Accepted: 09/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Available data on mycophenolate mofetil (MMF), azathioprine (AZA) and methotrexate (MTX) for paediatric-onset anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is limited. METHODS Systematic literature review on patients treated with MMF/AZA/MTX for paediatric-onset anti-NMDARE, with focus on modes of use, efficacy and safety. RESULTS 87 patients were included (age at onset median 11 years, range 0.8-18 years; 69% females). 46% had a relapsing course. 52% received MMF, 27% AZA, 15% MTX, and 6% a combination of MMF/AZA/MTX (7 patients received intrathecal MTX). Before MMF/AZA/MTX, 100% patients received steroids, 83% intravenous immunoglobulin and 45% plasma exchange, and 50% received second-line treatments (rituximab/cyclophosphamide). MMF/AZA/MTX were administered >6 months from onset in 51%, and only after relapse in 40%. Worst mRS before MMF/AZA/MTX was median 4.5 (range 3-5). At last follow-up (median 2 years, range 0.2-8.6), median mRS was 1 (range 0-6). Median annualised relapse rate was 0.4 (range 0-6.7) pre-MMF/AZA/MTX (excluding first events), and 0 on MMF/AZA/MTX (mean 0.03, range 0-0.8). 7% patients relapsed on MMF/AZA/MTX. These relapsing patients had low rate of second-line treatments before MMF/AZA/MTX (25%), long median time between onset and MMF/AZA/MTX usage (18 months), and frequently they were started on MMF/AZA/MTX only after relapse (75%). Relapse rate was lower among patients who received first immune therapy ≤30 days (25%) than later (64%), who received second-line treatments at first event (14%) rather than not (64%), who were started on MMF/AZA/MTX after the first (12%) rather than subsequent events (17%), and who were started on MMF/AZA/MTX ≤3 months from onset (33%) rather than later (53%). Adverse reactions to MMF/AZA/MTX occurred in 2 cases (cytomegalovirus colitis and respiratory infection), of grade 3 Common Terminology Criteria for Adverse Events v4.0. DISCUSSION Our literature review disclosed heterogeneity in the use of MMF/AZA/MTX in paediatric-onset anti-NMDARE. MMF/AZA/MTX usage is mostly restricted to retrospective cohort descriptions. These agents may reduce risk of relapse, and have a reasonable safety profile, however data on larger cohorts are required to definitively determine effect.
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do Valle DA, Galeazzi JSP, Machado MR, Dos Santos VCSAR, da Silva AF, Lohr Júnior A, Santos MLSF, Scola RH. Clinical variability of children with anti-N-methyl-D-aspartate receptor encephalitis in southern Brazil: a cases series and review of the literature. Neurol Sci 2019; 40:351-6. [PMID: 30460460 DOI: 10.1007/s10072-018-3648-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/13/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated disease of the central nervous system (CNS). The aim of this study was to describe the variability of clinical presentation in anti-NMDAR encephalitis, treatment and outcomes in a case series of children and adolescents. METHODS Retrospectively analyse patients diagnosed with anti-NMDAR encephalitis, from 2010 to 2018. RESULTS The study population consisted of nine children with anti-NMDAR encephalitis from southern Brazil, six females and three males, aged 5 months to 16 years (mean 5 years). The time of follow-up varied between 1 and 7 years, with a mean of 3 years. The most frequent first manifestation consisted of seizures. All patients described had psychiatric symptoms and a wide spectrum of neurologic findings. Five patients had unilateral symptoms. Magnetic resonance imaging and electroencephalogram were normal in most patients. Cerebrospinal fluid pleocytosis occurred in five patients. All patients were administered immunoglobulin and/or steroids. Seven patients (78%) required cyclophosphamide and/or rituximab. Almost half of the patients fully recovered from all symptoms. CONCLUSIONS A wide variety of symptoms were observed in this study and, although unilateral symptoms are rarely reported in the literature, a high frequency was observed among Brazilian children. Alternatives to first-line therapy should be considered in patients with clinical suspicion, even if they have not had a good response with first-line therapy.
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Cainelli E, Nosadini M, Sartori S, Suppiej A. Neuropsychological And Psychopathological Profile Of Anti-Nmdar Encephalitis: A Possible Pathophysiological Model For Pediatric Neuropsychiatric Disorders. Arch Clin Neuropsychol 2019; 34:1309-19. [DOI: 10.1093/arclin/acy088] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/30/2018] [Accepted: 10/18/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is a severe, but treatable, autoimmune disorder, characterized by autoantibodies causing hypofunction of blocking NMDA receptors leading to a unique constellation of cognitive, motor, and psychiatric symptoms. Neuropsychological and psychopathological outcome has not been fully explored, particularly in children. Aim of this study was to investigate pediatric anti-NMDAR encephalitis as a model of impairment of the complex frontal-subcortical circuits who are implicated in several of the childhood neuropsychiatric disorders.
Method
Seven children diagnosed with anti-NMDAR encephalitis at our department underwent an evaluation of the global mental functioning before discharge, a neuropsychological and psychological/behavioral standardized examination within one month after discharge and subsequently were followed up longitudinally for mean 35 months (range 24–48 months). Collected neuropsychological data were evaluated retrospectively.
Results
Deficits in attention, executive functions and/or visual motor functions involving executive functions were seen in all children within one month after discharge. These deficits were long lasting in about a half of the patients. In addition, four patients developed persistent psychopathological dysfunctions: difficulties to regulate their own behavior, impulsivity, hyperactivity, irritability, apathy, and obsessive-compulsive symptoms.
Conclusions
Our data are in line with research suggesting a crucial role of the executive functions impairments in cognitive outcome disturbance of anti-NMDAR encephalitis. We found also behavioral and psychological deficits pointing to a more comprehensive framework of frontal-subcortical dysfunction, in which the NMDA mediated transmission appear to have a role, as suggested by neurobiological, pharmacological, and neuroimaging studies.
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Sakpichaisakul K, Patibat L, Wechapinan T, Sri-udomkajrorn S, Apiwattanakul M, Suwannachote S. Heterogenous treatment for anti-NMDAR encephalitis in children leads to different outcomes 6–12 months after diagnosis. J Neuroimmunol 2018; 324:119-25. [DOI: 10.1016/j.jneuroim.2018.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/09/2018] [Accepted: 09/17/2018] [Indexed: 11/20/2022]
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Espinola-Nadurille M, Bautista-Gomez P, Flores J, Rivas-Alonso V, Perez-Esparza R, Solís-Vivanco R, Vargas-Cañas S. Non-inflammatory cerebrospinal fluid delays the diagnosis and start of immunotherapy in anti-NMDAR encephalitis. Arq Neuropsiquiatr 2018; 76:2-5. [PMID: 29364387 DOI: 10.1590/0004-282x20170179] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/29/2017] [Indexed: 11/22/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalopathy that presents with a wide variety of symptoms, including neuropsychiatric manifestations. The authors' aim for this study was to analyze the results of paraclinical studies of patients with a diagnosis of anti-NMDAR encephalitis and the association between symptom onset and diagnosis, and start of immunotherapy. Retrospective data of 29 patients with anti-NMDAR encephalitis were gathered and analyzed. Abnormal EEG was found in 27 patients (93.1%), whereas MRI was abnormal in 19 patients (65.5%). In contrast, an inflammatory pattern on CSF analysis was found in only 13 patients (44.8%). The absence of pleocytosis or increased proteins in the CSF was associated with a longer time from symptom onset to diagnosis and treatment (p = 0.003). The authors conclude that noninflammatory CSF may delay the correct diagnosis and start of immunotherapy in anti-NMDAR encephalitis. In the presence of suggestive clinical features, extensive studies including EEG are recommended.
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Affiliation(s)
- Mariana Espinola-Nadurille
- Instituto Nacional de Neurología y Neurocirugía, Unidad de Neuropsiquiatría, Ciudad de México, México.,Universidad Nacional Autónoma de México, Facultad de Medicina, División de Posgrado, Ciudad de México, México
| | - Paola Bautista-Gomez
- Instituto Nacional de Neurología y Neurocirugía, Unidad de Neuropsiquiatría, Ciudad de México, México
| | - Jose Flores
- Instituto Nacional de Neurología y Neurocirugía, Subdirección de Neurología, Ciudad de México, México
| | - Veronica Rivas-Alonso
- Instituto Nacional de Neurología y Neurocirugía, Subdirección de Neurología, Ciudad de México, México
| | - Rodrigo Perez-Esparza
- Instituto Nacional de Neurología y Neuricrugía, Laboratorio de Investigación en Adicciones, Ciudad de México, México
| | - Rodolfo Solís-Vivanco
- Instituto Nacional de Neurología y Neurocirugía, Departamento de Neuropsicología, Ciudad de México, México.,Universidad Nacional Autónoma de México, Facultad de Psicología, Ciudad de México, México
| | - Steven Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía, Subdirección de Neurología, Ciudad de México, México
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Kasinathan A, Adam RK, Sankhyan N, Singhi P. Apathy - Forme Fruste of Autoimmune Encephalitis. Indian J Pediatr 2018. [PMID: 29532325 DOI: 10.1007/s12098-018-2652-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ananthanarayanan Kasinathan
- Pediatric Neurology and Neurodevelopment Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Razia K Adam
- Department of Pediatrics, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, 201310, India
| | - Naveen Sankhyan
- Pediatric Neurology and Neurodevelopment Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Pratibha Singhi
- Department of Pediatrics, Medanta, The Medicity, Gurgaon, India
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Abstract
RATIONALE Autoimmune encephalitis related to many antibodies against neuronal cell surface or synaptic proteins, it is increasingly recognized as the cause of a variety of neuropsychiatric syndromes. PATIENT CONCERNS The two pediatric cases were about autoimmune encephalitis with rare complication. One patient was a 11-year-old girl and was diagnosed with Voltage-Gated Potassium Channel complex (VGKC) antibody-mediated encephalitis with rhabdomyolysis; the other was also a 11-year-old girl and was diagnosed with anti- N-methyl-D-aspartate receptor (NMDAR) encephalitis. DIAGNOSES Both patients were diagnosed as autoimmune encephalitis with rare complication. INTERVENTIONS Intravenous methylprednisolone, oral prednisone and intravenous immunoglobulin was administered to both patients. OUTCOMES One patient was discharged after a half month's hospitalization; the other was finally with intestinal function failure, gradually developed multiple organ failure, and eventually died. LESSONS The pathogenic mechanism of autoimmune encephalitis associated with autoimmune disease is not fully understood, but may be related to a common immune pathological mechanism with variance in susceptibility caused by genetic or environmental factors.
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Affiliation(s)
- Rong Li
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Xiu-juan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Si-qi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Min Zhong
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
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Ho ACC, Chan SHS, Chan E, Wong SSN, Fung STH, Cherk SWW, Fung ELW, Ma KH, Tsui KW, Yau EKC, Wong VCN. Anti-N-methyl-d-aspartate receptor encephalitis in children: Incidence and experience in Hong Kong. Brain Dev 2018; 40:473-479. [PMID: 29599011 DOI: 10.1016/j.braindev.2018.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/07/2018] [Accepted: 02/07/2018] [Indexed: 12/19/2022]
Abstract
AIM The study aims to analyze the incidence, clinical features, investigation findings and treatment outcomes of anti-N-methyl-d-aspartate receptor encephalitis in children from Hong Kong. METHOD A retrospective study was carried out on paediatric patients diagnosed with anti-NMDAR encephalitis in Hong Kong from January 2009 to December 2015. RESULTS Fifteen patients (67% female, 93% Chinese) were identified over seven years and the estimated incidence in Hong Kong was 2.2/million children per year (95% CI 1.2-3.6). The median age of presentation was 12 years (range 1-17 years). The most common symptom groups observed were abnormal psychiatric behavior or cognitive dysfunction (14/15, 93%) and seizures (14/15, 93%), followed by speech dysfunction (13/15, 87%), movement disorders (12/15, 80%), decreased level of consciousness (10/15, 67%) and autonomic dysfunction or central hypoventilation (5/15, 33%). The median number of symptom groups developed in each patient was 5 (range 3-6). All patients were treated with intravenous immunoglobulin and/or steroids. Three patients (20%) with more severe presentation required additional plasmapheresis and rituximab. Outcome was assessable in 14 patients. Among those eleven patients who had only received intravenous immunoglobulin and/or steroids, nine patients (82%) achieved full recovery. One patient (9%) had residual behavioral problem, while another one (9%) who developed anti-NMDAR encephalitis after herpes simplex virus encephalitis was complicated with dyskinetic cerebral palsy and epilepsy. Among those three patients who required plasmapheresis and rituximab, one (33%) had full recovery and two (66%) had substantial recovery. The median duration of follow up was 20.5 months (range 3-84 months). CONCLUSION Anti-NMDAR encephalitis is an acquired, severe, but potentially treatable disorder. Ethnicity may play a role in the incidence of anti-NMDAR encephalitis and we have provided a local incidence with the majority of patients being Chinese. The diagnosis of anti-NMDAR encephalitis should be considered in children presenting with a constellation of symptoms including psychiatric and neurological manifestations. Patients may respond to first line immunotherapy. For those who do not, second line therapy is indicated in order to achieve a better outcome.
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Affiliation(s)
- Alvin Chi-Chung Ho
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Sophelia Hoi-Shan Chan
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Eric Chan
- Division of Clinical Immunology, Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong
| | - Sheila Suet-Na Wong
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong
| | | | | | | | - Kam-Hung Ma
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Kwing-Wan Tsui
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Eric Kin-Cheong Yau
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Virginia Chun-Nei Wong
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Motamed-Gorji N, Matin N, Tabatabaie O, Pavone P, Romano C, Falsaperla R, Vitaliti G. Biological Drugs in Guillain-Barré Syndrome: An Update. Curr Neuropharmacol 2018; 15:938-950. [PMID: 27964705 PMCID: PMC5652014 DOI: 10.2174/1570159x14666161213114904] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/25/2022] Open
Abstract
Background: Guillain-Barré Syndrome (GBS) is currently considered the most common global cause of acute flaccid paralysis. Currently, standard therapy for Guillain-Barré Syndrome includes intravenous immunoglobulin or plasma exchange. Despite medical advances regarding these treatments, many treated patients do not reach full recovery. Therefore several biological agents have attracted the attentions from researchers during the last decades, and various studies have investigated their role in Guillain-Barré Syndrome. Objective: The present study aims to address emerging biological approaches to GBS while considering their efficiency and safety in treating the disease. Materials and Methods: An extensive electronic literature search was conducted by two researchers from April 2016 to July 2016. Original articles, clinical trials, systematic reviews (with or without meta-analysis) and case reports were selected. Titles and abstracts of papers were screened by reviewers to determine whether they met the eligibility criteria, and full texts of the selected articles were retrieved. Results: Herein authors focused on the literature data concerning emerging biological therapeutic agents, namely anti-C5 monoclonal antibody (Eculizumab), anti-C1q monoclonal antibody, anti-T cell monoclonal antibody, anti-CD2 monoclonal antibody, anti L-selectin monoclonal antibody, anti-CD20 monoclonal antibody (Rituximab), anti-CD52 monoclonal antibody (Alemtuzumab) and cytokine targets. By far, none of these agents have been approved for the treatment of GBS by FDA. Conclusion: Literature findings represented in current review herald promising results for using these biological targets. Current review represents a summary of what is already in regards and what progress is required to improve the immunotherapeutic approach of treating GBS via future studies.
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Affiliation(s)
| | - Nassim Matin
- Department of Neurology, Massachusetts General Hospital, Boston, MA. United States
| | - Omidreza Tabatabaie
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. United States
| | - Piero Pavone
- General Paediatrics Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania. Italy
| | - Catia Romano
- General Paediatrics Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania. Italy
| | - Raffaele Falsaperla
- General Paediatrics Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania. Italy
| | - Giovanna Vitaliti
- General Paediatrics Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania. Italy
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Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) is an increasingly recognized etiology for neuropsychiatric deficits that are highly responsive to immunotherapy. As a result, rheumatologists are often called upon to help with the diagnosis and treatment of these conditions. The purpose of this review is to provide an update on the pharmacologic treatment of AE. RECENT FINDINGS To date, there are no prospective randomized placebo-controlled trials to guide treatment recommendations for AE. First-line therapies include corticosteroids, intravenous immunoglobulin, and plasma exchange. Second-line therapies include rituximab and cyclophosphamide (CYC), as well as mycophenolate mofetil and azathioprine. For patients refractory to both first- and second-line therapy, there is emerging evidence for the interleukin-6 (IL-6) inhibitor tocilizumab, the proteasome inhibitor bortezomib, and low-dose IL-2. Early treatment initiation and treatment escalation in patients with refractory disease improve outcomes. Given the delayed time between dosing and treatment effects of second-line agents, continuing first-line treatment until the patients shows improvement is recommended. SUMMARY Although AE can present with dramatic, life-threatening neuropsychiatric deficits, the potential for recovery with prompt treatment is remarkable. First- and second-line therapies for AE lead to clinical improvement in the majority of patients, including full recoveries in many. Early treatment and escalation to second-line therapy in those with refractory disease improves patient outcomes. Novel treatments including IL-6 blockade and proteasome inhibitors have shown promising results in patients with refractory disease.
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Affiliation(s)
- Cory Stingl
- Division of Pediatric Rheumatology, Duke University, Durham, NC, USA
| | | | - Heather Van Mater
- Division of Pediatric Rheumatology, Duke University, Durham, NC, USA
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Konuskan B, Yildirim M, Topaloglu H, Erol I, Oztoprak U, Tan H, Gocmen R, Anlar B. Clinical presentation of anti-N-methyl-d-aspartate receptor and anti-voltage-gated potassium channel complex antibodies in children: A series of 24 cases. Eur J Paediatr Neurol 2018; 22:135-42. [PMID: 29153996 DOI: 10.1016/j.ejpn.2017.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 05/21/2017] [Accepted: 10/30/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The symptomatology and paraclinical findings of antibody-mediated encephalitis, a relatively novel disorder, are still being characterized in adults and children. A high index of suspicion is needed in order to identify these cases among children presenting with various neurological symptoms. The aim of this study is to examine the clinical, demographic and laboratory findings and outcome of children with anti-NMDAR and anti-VGKC encephalitis for any typical or distinctive features. METHODS Cases diagnosed with anti-N-Methyl d-aspartate receptor (NMDAR) and anti-voltage gated potassium channel (VGKC) antibody-mediated encephalopathy in four major child neurology centers are described. RESULTS In four years, 16 children with NMDAR and 8 children with VGKC antibody-associated disease were identified in the participating centers. The most frequent initial manifestation consisted of generalized seizures and cognitive symptoms in both groups. Movement abnormalities were frequent in anti-NMDAR patients and autonomic symptoms, in anti-VGKC patients. Cerebrospinal fluid (CSF) protein, cell count and IgG index were normal in 9/15 anti-NMDAR and 5/8 anti-VGKC patients tested. EEG and MRI findings were usually nonspecific and non-contributory. The rate and time of recovery was not related to age, sex, acute or subacute onset, antibody type, MRI, EEG or CSF results. Treatment within 3 months of onset was associated with normal neurological outcome. CONCLUSIONS Our results suggest anti-NMDAR and VGKC encephalopathies mostly present with non-focal neurological symptoms longer than 3 weeks. In contrast with adult cases, routine CSF testing, MRI and EEG did not contribute to the diagnosis in this series.
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Uchida Y, Kato D, Yamashita Y, Ozaki Y, Matsukawa N. Failure to improve after ovarian resection could be a marker of recurrent ovarian teratoma in anti-NMDAR encephalitis: a case report. Neuropsychiatr Dis Treat 2018; 14:339-342. [PMID: 29403279 PMCID: PMC5784750 DOI: 10.2147/ndt.s156603] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a type of autoimmune encephalitis that can be paraneoplastic and usually responds to tumor resection and immunotherapy. More than 75% of patients with anti-NMDAR encephalitis fully recover or have only mild sequelae, whereas the remainder experience severe disability. It remains unknown why certain cases have refractory clinical disease courses. We report a case of anti-NMDAR encephalitis with bilateral ovarian teratomas who was refractory to tumor resection and early initiation of immunotherapy. During intensive care, immunohistochemical analyses of her cerebrospinal fluid showed persistently high reactivity of NMDAR antibody over time. Six months after the operation, pelvic computed tomography detected a recurrent ovarian teratoma. After total enucleation of the bilateral ovaries, with significant pathological findings of bilateral mature cystic teratomas, her clinical condition improved rapidly, paralleled by a decrease in anti-NMDAR reactivity. This case illustrates the need to keep considering why extensive treatment fails to influence the disease when we encounter patients with refractory anti-NMDAR encephalitis. Failure to improve after ovarian resection could be a marker of recurrent ovarian teratoma in anti-NMDAR encephalitis.
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Affiliation(s)
| | | | | | - Yasuhiko Ozaki
- Department of Obstetrics and Gynecology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Liu X, Yan B, Wang R, Li C, Chen C, Zhou D, Hong Z. Seizure outcomes in patients with anti-NMDAR encephalitis: A follow-up study. Epilepsia 2017; 58:2104-2111. [PMID: 29098690 DOI: 10.1111/epi.13929] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Xu Liu
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Bo Yan
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Rui Wang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Chen Li
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Chu Chen
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Dong Zhou
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
| | - Zhen Hong
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan China
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Goldberg TN, Cellucci MF. New Onset Insomnia in a Pediatric Patient: A Case of Anti-NMDA Receptor Encephalitis. Case Rep Pediatr 2017; 2017:4083785. [PMID: 28770118 DOI: 10.1155/2017/4083785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/18/2017] [Accepted: 06/05/2017] [Indexed: 12/13/2022] Open
Abstract
Anti-NMDAR encephalitis is becoming more widely recognized as a cause of encephalopathy in both adults and children. Certain clinical features such as mood lability, movement disorders, speech dysfunction, seizures, and autonomic instability in a pediatric patient should prompt immediate concern and evaluation for autoimmune encephalitis among providers. We present the case of a pediatric patient with anti-NMDAR encephalitis in which the symptom prompting medical evaluation was insomnia. Insomnia has not previously been emphasized in the literature as a presenting feature of this disease in children and has a broad differential. Recognition of the symptoms of anti-NMDAR encephalitis and its variable presentation are key to early diagnosis and prompt initiation of treatment which may help to improve outcomes.
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Nosadini M, Mohammad SS, Corazza F, Ruga EM, Kothur K, Perilongo G, Frigo AC, Toldo I, Dale RC, Sartori S. Herpes simplex virus-induced anti-N-methyl-d-aspartate receptor encephalitis: a systematic literature review with analysis of 43 cases. Dev Med Child Neurol 2017; 59:796-805. [PMID: 28439890 DOI: 10.1111/dmcn.13448] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2017] [Indexed: 01/05/2023]
Abstract
AIM To conduct a systematic literature review on patients with biphasic disease with herpes simplex virus (HSV) encephalitis followed by anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHOD We conducted a case report and systematic literature review (up to 10 December 2016), focused on differences between herpes simplex encephalitis (HSE) and anti-NMDAR encephalitis phases, age-related characteristics of HSV-induced anti-NMDAR encephalitis, and therapy. For statistical analyses, McNemar's test, Fisher's test, and Wilcoxon rank sum test were used (two-tailed significance level set at 5%). RESULTS Forty-three patients with biphasic disease were identified (31 children). Latency between HSE and anti-NMDAR encephalitis was significantly shorter in children than adults (median 24 vs 40.5d; p=0.006). Compared with HSE, anti-NMDAR encephalitis was characterized by significantly higher frequency of movement disorder (2.5% vs 75% respectively; p<0.001), and significantly lower rate of seizures (70% vs 30% respectively; p=0.001). Compared with adults, during anti-NMDAR encephalitis children had significantly more movement disorders (86.7% children vs 40% adults; p=0.006), fewer psychiatric symptoms (41.9% children vs 90.0% adults; p=0.025), and a slightly higher median modified Rankin Scale score (5 in children vs 4 in adults; p=0.015). During anti-NMDAR encephalitis, 84.6 per cent of patients received aciclovir (for ≤7d in 22.7%; long-term antivirals in 18.0% only), and 92.7 per cent immune therapy, but none had recurrence of HSE clinically or using cerebrospinal fluid HSV polymerase chain reaction (median follow-up 7mo). INTERPRETATION Our review suggests that movement disorder may help differentiate clinically an episode of HSV-induced anti-NMDAR encephalitis from HSE relapse. Compared with adults, children have shorter latency between HSE and anti-NMDAR encephalitis and, during anti-NMDAR encephalitis, more movement disorder, fewer psychiatric symptoms, and slightly more severe disease. According to our results, immune therapy given for HSV-induced anti-NMDAR encephalitis does not predispose patients to HSE recurrence.
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Affiliation(s)
- Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Shekeeb S Mohammad
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Francesco Corazza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Ezia Maria Ruga
- Department of Paediatrics, University of Padua, Padua, Italy
| | - Kavitha Kothur
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | | | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Padua, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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Jones HF, Mohammad SS, Reed PW, Dunn PPJ, Steele RH, Dale RC, Sharpe C. Anti-N-methyl-d-aspartate receptor encephalitis in Māori and Pacific Island children in New Zealand. Dev Med Child Neurol 2017; 59:719-724. [PMID: 28328164 DOI: 10.1111/dmcn.13420] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2017] [Indexed: 12/19/2022]
Abstract
AIM To investigate the incidence and severity of anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis in children from New Zealand. METHOD A retrospective case series was undertaken of all children (≤18y) diagnosed with anti-NMDA receptor encephalitis from January 2008 to October 2015. RESULTS Sixteen patients were identified with anti-NMDA receptor antibodies in the cerebrospinal fluid, three of whom had an associated teratoma. Fifteen children had Māori and/or Pacific Island ancestry. The incidence of anti-NMDA receptor encephalitis in Māori children was 3.4 per million children per year (95% confidence interval [CI] 1.4-7.0) and the incidence in Pacific children was 10.0 per million children per year (95% CI 4.3-19.8) compared with 0.2 per million children per year (95% CI 0.0-1.0) in children without Māori or Pacific Island ancestry. Sixty-seven per cent of children had a good outcome (modified Rankin Score ≤2) at 2 years' follow-up. This compares unfavourably with other cohorts despite a shorter median time to first-line immunotherapy (13d; range 4-89) and a higher proportion of children being treated with second-line therapy (50%). INTERPRETATION Māori and Pacific Island children have a higher incidence of anti-NMDA receptor encephalitis and possibly a more severe phenotype. These data suggest a genetic predisposition to anti-NMDA receptor encephalitis in these populations.
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Affiliation(s)
| | | | - Peter W Reed
- Starship Children's Hospital, Auckland, New Zealand
| | | | | | - Russell C Dale
- The Children's Hospital at Westmead, Westmead, NSW, Australia
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Liu CY, Zhu J, Zheng XY, Ma C, Wang X. Anti-N-Methyl-D-aspartate Receptor Encephalitis: A Severe, Potentially Reversible Autoimmune Encephalitis. Mediators Inflamm. 2017;2017:6361479. [PMID: 28698711 PMCID: PMC5494059 DOI: 10.1155/2017/6361479] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/04/2017] [Indexed: 02/06/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is potentially lethal, but it is also a treatable autoimmune disorder characterized by prominent psychiatric and neurologic symptoms. It is often accompanied with teratoma or other neoplasm, especially in female patients. Anti-NMDAR antibodies in cerebrospinal fluid (CSF) and serum are characteristic features of the disease, thereby suggesting a pathogenic role in the disease. Here, we summarize recent studies that have clearly documented that both clinical manifestations and the antibodies may contribute to early diagnosis and multidisciplinary care. The clinical course of the disorder is reversible and the relapse could occur in some patients. Anti-NMDAR encephalitis coexisting with demyelinating disorders makes the diagnosis more complex; thus, clinicians should be aware of the overlapping diseases.
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Falsaperla R, Romano C, Pavone P, Vitaliti G, Yuan Q, Motamed-Gorji N, Lubrano R. The Gut-brain Axis: A New Pathogenic View of Neurologic Symptoms - Description of a Pediatric Case. J Pediatr Neurosci 2017; 12:105-108. [PMID: 28553399 PMCID: PMC5437772 DOI: 10.4103/jpn.jpn_190_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Recent literature data have given emphasis to the relationship between gastrointestinal (GI) disorders and neurologic diseases, underlying a new pathogenic pathway: The so-called “gut–brain axis.” Herein, authors report a case of a 10-month-old male infant, admitted for drug-resistant epilepsy, associated with irritable behavior and GI discomfort, secondary to cow's milk protein allergy. Seizures were described by parents as upward eye movements that were mostly deviated to the right and were associated with slight extension of his neck. They were infrequent at first, but had increased gradually during the course of 3 days (up to 15–20 times/day). No anticonvulsant therapy was effective. Only a cow's milk protein-free diet, accidentally started during a gastroenteritis episode, was effective in stopping seizures. Our case underlines the peculiar vulnerability of the blood–brain barrier under 1 year of age, for which children of this age group experience neurologic manifestations during episodes of systemic inflammation.
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Affiliation(s)
- Raffaele Falsaperla
- General Paediatrics Complex Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania, Italy
| | - Catia Romano
- General Paediatrics Complex Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania, Italy
| | - Piero Pavone
- General Paediatrics Complex Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania, Italy
| | - Giovanna Vitaliti
- General Paediatrics Complex Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Catania, Italy
| | - Qian Yuan
- Clinical Director, Food Allergy Center, Pediatrician, Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Department of Pediatrics, Harvard Medical School, Boston, USA
| | | | - Riccardo Lubrano
- Pediatric Nephrology Operative Unit, La Sapienza University of Rome, Rome, Italy
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Abstract
Autoimmune (antibody mediated) encephalitis (AE) is emerging as a more common cause of pediatric encephalopathy than previously thought. The autoimmune process may be triggered by an infection, vaccine, or occult neoplasm. In the latter case, onconeural autoantibodies are directed against intracellular neuronal antigens, but a recent heterogeneous group of encephalitic syndromes has been found not to have underlying tumor but is associated with autoantibodies to the neuronal surface or synaptic antigens. Neuropsychiatric symptoms are very common in autoimmune encephalopathy; as a result, affected children may be initially present to psychiatrists. Neurological features are movement disorders, seizures, altered conscious level, and cognitive regression. Hypoventilation and autonomic features may be an aspect. Inflammatory findings in the cerebrospinal fluid may be present but are relatively nonspecific. Magnetic resonance imaging (MRI) may also demonstrate abnormalities that provide clues for diagnosis, particularly on fluid-attenuated inversion recovery or T2-weighted images. AE is well responsive to immune therapy, with prompt diagnosis and treatment strongly beneficial. Patients with paraneoplastic encephalitis are more refractory to treatment compared to those in whom no malignancy is identified. Herein, the authors present an update of literature data on the clinical presentation, laboratory and imaging findings, therapy, and outcomes for the most common autoimmune encephalitides.
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Affiliation(s)
- Massimo Barbagallo
- Department of Paediatrics, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione "Garibaldi", Catania, Italy
| | - Giovanna Vitaliti
- Department of Paediatrics, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Piero Pavone
- Department of Paediatrics, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Catia Romano
- Department of Paediatrics, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Riccardo Lubrano
- Department of Paediatrics, "La Sapienza" University, Rome, Italy
| | - Raffaele Falsaperla
- Department of Paediatrics, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
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Yamada A, Miyachi N, Miura T, Suzuki M, Watanabe N, Akechi T. Long-term poor rapport, lack of spontaneity and passive social withdrawal related to acute post-infectious encephalitis: a case report. Springerplus 2016; 5:345. [PMID: 27652003 PMCID: PMC4798482 DOI: 10.1186/s40064-016-1994-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 03/11/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Post-infectious encephalitis/encephalopathy is a neurological syndrome that sometimes develops following common viral or bacterial infections. The most common form is acute disseminated encephalomyelitis (ADEM). ADEM is a demyelinating disease of the central nervous system that typically presents as a monophasic disorder associated with multifocal neurologic symptoms and encephalitis. Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is another type of severe autoimmune disorder, characterized by seizures, movement disorders and psychiatric symptoms. In general, the prognosis and long-term outcomes of both ADEM and anti-NMDAR encephalitis are favorable. Most patients show complete, albeit slow recovery over a period of one to 2 years. There are few reports of patients with these disorders showing long-term residual psychiatric symptoms. CASE PRESENTATION We report the case of a 16-year-old Japanese male who suffered from acute post-infectious encephalitis. The patient followed an atypical recovery course, in that he showed poor rapport, lack of spontaneity and passive social withdrawal for more than 2 years after the initial symptoms. While treatment with small doses of antipsychotic drugs at the hospital had no effect on the symptoms, the patient recovered gradually over a prolonged period of five or so years. CONCLUSIONS This case report suggests that a type of acute post-infectious encephalitis with demyelinating features, possibly ADEM or anti-NMDAR encephalitis, or an overlap between the two, can cause a prodrome of behavioral changes and long-term residual psychiatric symptoms for many months, although it is eventually associated with a good prognosis.
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Affiliation(s)
- Atsurou Yamada
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuhiro Miyachi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Koseikan Hospital, Ama, Aichi Japan
| | - Toshiyasu Miura
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masako Suzuki
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Norio Watanabe
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Duan BC, Weng WC, Lin KL, Wong LC, Li ST, Hsu MH, Lin JJ, Fan PC, Lin MI, Chiu NC, Lin YC, Wang HS, Hung KL, Lee WT. Variations of movement disorders in anti-N-methyl-D-aspartate receptor encephalitis: A nationwide study in Taiwan. Medicine (Baltimore) 2016; 95:e4365. [PMID: 27631202 PMCID: PMC5402545 DOI: 10.1097/md.0000000000004365] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/09/2016] [Accepted: 07/01/2016] [Indexed: 12/19/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the most common autoimmune encephalitis that presents with a wide variety of movement disorders. The purpose of our study is to review the manifestations and duration of movement disorders in different ages with NMDAR encephalitis.A retrospective cohort of 28 patients (20 females and 8 males) with positive cerebrospinal fluid (CSF) anti-NMDAR antibody in a 5-year period from major hospitals in Taiwan was enrolled. They were categorized into 3 age groups: 7 patients were ≤10 years, 14 patients were 10 to 18 years, and 7 patients were >18 years.Total 28 patients (20 females and 8 males) with age ranging from 8 months to 38 years were enrolled. Nearly all patients (n = 27/28, 96%) presented with at least 2 types of disorders, including orofacial-lingual dyskinesia (OFLD; n = 20), catatonia (n = 19), tremor (n = 11), bradykinesia (n = 11), dystonia (n = 11), choreoathethosis (n = 9), and ballism (n = 3). Only 1 patient below 10 years presented with isolated periodic choreoathethosis without other movement disorders. OFLD was common in all age groups. Choreoathetosis was most common in patients aged ≤10 years, while catatonia was most common in patients aged >10 years (P = 0.001 and 0.020, respectively). Bradykinesia was also more common in patients aged >10 years (P = 0.020). The clinical presentations of movement disorders were not significantly different in the age of 10 to 18 years and those >18 years. Neither patient ≤10 years old nor male patients had associated tumors. All patients' movement disorders were improved after treatment, while female patients with tumors had worse short-term outcome (P = 0.014). Compared with other disorders, choreoathetosis persisted significantly longer in patients ≤10 years (P = 0.038), while OFLD and catatonia last longer in patients >10 years (P = 0.047 and 0.002, respectively).Our study shows that hyperkinetic movements such as choreoathetosis are more common and last longer in younger age groups, whereas hypokinetic movements such as catatonia and bradykinesia are more common and last longer in older age groups. Female patients with ovarian tumors had worse short-term outcome.
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Affiliation(s)
- Bi-Chun Duan
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Wen-Chin Weng
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Lee Chin Wong
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Sung-Tse Li
- Department of Pediatrics, Hsinchu Mackay Memorial Hospital, Hsinchu
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Pi-Chaun Fan
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Ming-I. Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, Mackay Memorial Hospital, Taipei
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Kun-Long Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
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Suppiej A, Nosadini M, Zuliani L, Pelizza MF, Toldo I, Bertossi C, Tison T, Zoccarato M, Marson P, Giometto B, Dale RC, Sartori S. Plasma exchange in pediatric anti-NMDAR encephalitis: A systematic review. Brain Dev 2016; 38:613-22. [PMID: 26926399 DOI: 10.1016/j.braindev.2016.01.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/19/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To clarify the most frequent modalities of use of plasma exchange (PE) in pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis and to establish the most effective association with other immunotherapies. METHODS Systematic literature review on PE in pediatric anti-NMDAR encephalitis (2007-2015). RESULTS Seventy-one articles were included (mostly retrospective), reporting a total of 242 subjects (73.2%, 93/127 females; median age at onset 12years, range 1-18). Median time to immunotherapy was 21days (range 0-190). In most cases, PE was given with steroids and IVIG (69.5%, 89/128), or steroids only (18%, 23/128); in a minority, it was associated with IVIG only (7%, 9/128), or was the only first-line treatment (5.5%, 7/128). In 54.5% (65/119), PE was the third treatment after steroids and IVIG, in 31.1% (37/119) the second after steroids or IVIG; only in 14.3% (17/119) was it the first treatment. Second-line immunotherapies were administered in 71.9% (100/139). Higher rates of full/substantial recovery at follow-up were observed with immunotherapy given ⩽30days from onset (69.4%, 25/36) compared to later (59.2%, 16/27), and when PE was associated with steroids (66.7%, 70/105) rather than not (46.7%, 7/15). Significant adverse reactions to PE were reported in 6 patients. CONCLUSION Our review disclosed a paucity of quality data on PE in pediatric anti-NMDAR encephalitis. PE use in this condition has been increasingly reported, most often with steroids and IVIG. Despite the limited number of patients, our data seem to confirm the trend towards a better outcome when PE was administered early, and when given with steroids.
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Affiliation(s)
- Agnese Suppiej
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy.
| | - Margherita Nosadini
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Luigi Zuliani
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Maria Federica Pelizza
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Irene Toldo
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Chiara Bertossi
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Tiziana Tison
- Immunotransfusion Section, University Hospital of Padua, Italy
| | - Marco Zoccarato
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Piero Marson
- Immunotransfusion Section, University Hospital of Padua, Italy
| | - Bruno Giometto
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Russell C Dale
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Australia
| | - Stefano Sartori
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
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Erazo R, González J, Quintanilla C, Devaud C, Gayoso C, Toledo X, Rauch E, Riffo C, Alvarez C, Salazar M, Salvo D, Dalmau J, Carmona O. [Subacute anti-N-methyl-D-aspartate receptor encephalitis. A serie of 13 paediatric cases]. ACTA ACUST UNITED AC 2016; 87:487-93. [PMID: 27476614 DOI: 10.1016/j.rchipe.2016.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/31/2016] [Accepted: 06/21/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Subacute anti-NMDA receptor encephalitis was recognised in 2007 as a clinical entity, and was first described in young women with ovarian teratoma. The first paediatric series unrelated with tumours was reported in 2009. OBJECTIVE To present the clinical features, treatment, and prognosis of 13 patients with anti-NMDA receptor encephalitis in Chile. PATIENTS AND METHOD A description is presented of 13 children, 9 males, aged between 1 and 16 years, diagnosed between 2009 and 2016 in 7 hospitals. All patients were evaluated with cerebral magnetic resonance and electroencephalogram. Cytochemical, oligoclonal bands and virus studies (PCR and antibodies) were performed in cerebrospinal fluid. All patients were evaluated in search of anti NMDA receptor in serum and cerebrospinal fluid. Tumor imaging studies were performed in all children. RESULTS All children began the disease with psychiatric symptoms, and 11/13 had seizures. All of them subsequently presented with psychomotor agitation, dystonia, and bucolingual dyskinesias, with 11/13 loss of language and 6/13 autonomic disorders. All of them (13/13) had positive anti-NMDA receptor antibodies. CSF was normal in 12/13 children, positive oligoclonal bands in 6/10 patients, normal brain resonance in 13/13 children, EEG changes in 11/13 children, and abnormal SPECT in 6/6 children. A methylprednisolone bolus of 30mg/kg was given for 3-5 days to 12/13 children, and 6 received immunoglobulin 2g/kg. The large majority (12/13) of children recovered 1-4 months after disease onset. One child had a recurrence one year later, and recovered quickly. CONCLUSIONS Subacute encephalitis due to NMDA anti-receptor antibodies should be suspected in children with psychiatric disorders and abnormal movements. Functional studies, such as EEG and SPECT are valuable diagnostic support. Early detection of this encephalitis leads to a faster recovery of patients.
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Scheer S, John RM. Anti-N-Methyl-D-Aspartate Receptor Encephalitis in Children and Adolescents. J Pediatr Health Care 2016; 30:347-58. [PMID: 26507948 DOI: 10.1016/j.pedhc.2015.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 12/18/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease that is becoming increasingly recognized in the pediatric population. It may be the most common cause of treatable autoimmune encephalitis. The majority of cases of anti-NMDAR encephalitis are idiopathic in etiology, but a significant minority can be attributed to a paraneoplastic origin. Children with anti-NMDAR encephalitis initially present with a prodrome of neuropsychiatric symptoms, often with orofacial dyskinesias followed by progressively worsening seizures, agitation, and spasticity, which may result in severe neurologic deficits and even death. Definitive diagnosis requires detection of NMDAR antibodies in the cerebrospinal fluid. Optimal outcomes are associated with prompt removal of the tumor in paraneoplastic cases, as well as aggressive immunosuppressive therapy. Early detection is essential for increasing the chances for a good outcome. Close follow-up is required to screen for relapse and later onset tumor presentation. The nurse practitioner plays a major role in the research, screening, diagnosis, treatment, follow-up, and rehabilitation of a child or adolescent with anti-NMDAR encephalitis.
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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