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Legouy C, Cervantes A, Sonneville R, Thakur KT. Autoimmune and inflammatory neurological disorders in the intensive care unit. Curr Opin Crit Care 2024; 30:142-150. [PMID: 38441114 DOI: 10.1097/mcc.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the diagnostic approach to autoimmune encephalitis (AE) in the intensive care unit (ICU) and provides practical guidance on therapeutic management. RECENT FINDINGS Autoimmune encephalitis represents a group of immune-mediated brain diseases associated with antibodies that are pathogenic against central nervous system proteins. Recent findings suggests that the diagnosis of AE requires a multidisciplinary approach including appropriate recognition of common clinical syndromes, brain imaging and electroencephalography to confirm focal pathology, and cerebrospinal fluid and serum tests to rule out common brain infections, and to detect autoantibodies. ICU admission may be necessary at AE onset because of altered mental status, refractory seizures, and/or dysautonomia. Early management in ICU includes prompt initiation of immunotherapy, detection and treatment of seizures, and supportive care with neuromonitoring. In parallel, screening for neoplasm should be systematically performed. Despite severe presentation, epidemiological studies suggest that functional recovery is likely under appropriate therapy, even after prolonged ICU stays. CONCLUSION AE and related disorders are increasingly recognized in the ICU population. Critical care physicians should be aware of these conditions and consider them early in the differential diagnosis of patients presenting with unexplained encephalopathy. A multidisciplinary approach is mandatory for diagnosis, ICU management, specific therapy, and prognostication.
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Affiliation(s)
- Camille Legouy
- GHU Paris Psychiatrie & Neurosciences, Department of Intensive Care Medicine, Paris, France
| | - Anna Cervantes
- Divisions of Neurocritical Care and Neuroinfectious Disease, Boston Medical Center, Boston, Massachusetts, USA
| | - Romain Sonneville
- Université Paris Cité, IAME, INSERM UMR1137
- AP-HP, Hôpital Bichat - Claude Bernard, Department of Intensive Care Medicine, Paris, France
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
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Vaisvilas M, Petrosian D, Bagdonaite L, Taluntiene V, Kralikiene V, Daugelaviciene N, Neniskyte U, Kaubrys G, Giedraitiene N. Seroprevalence of neuronal antibodies in diseases mimicking autoimmune encephalitis. Sci Rep 2024; 14:5352. [PMID: 38438516 PMCID: PMC10912693 DOI: 10.1038/s41598-024-55995-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/29/2024] [Indexed: 03/06/2024] Open
Abstract
Detection of neuronal antibodies for autoimmune encephalitis and paraneoplastic neurological syndromes relies on commercially available cell-based assays and lineblots. However, lineblots may reveal the presence of neuronal antibodies in patients with various non-autoimmune etiologies. Herein we describe patients with non-autoimmune etiologies (cohort B) and detectable neuronal antibodies and compare them to definite cases of autoimmune encephalitis (cohort A) for differences in clinical data. All patients positive for at least one neuronal antibody were retrospectively evaluated for autoimmune encephalitis and/or paraneoplastic neurological syndrome between 2016 and 2022. 39 cases in cohort B and 23 in cohort A were identified. In cohort B, most common diagnoses were neurodegenerative disorders in 9/39 (23.1%), brain tumors in 6/39 (15.4%) while most common detected antibodies were anti-titin (N10), anti-recoverin (N11), anti-Yo (N8) and all were detected in serum only. Differential aspects between cohort A and B were CSF pleocytosis (14/23 (60.8%) vs 11/35 (31.4%), p = 0.042, respectively), MRI features suggestive of encephalitis (6/23 (26.1%) vs 0 (0%), p = 0.002, respectively) and epilepsy restricted to temporal lobes (14/23 (60.9%) vs 2/30 (6.7%), p = 0.0003, respectively). A large proportion of lineblot results were non-specific when only serum was tested and were frequently found in non-autoimmune neurological conditions.
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Affiliation(s)
- Mantas Vaisvilas
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.
- Department of Neurology, Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08661, Vilnius, Lithuania.
| | | | - Loreta Bagdonaite
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Vera Taluntiene
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Viktorija Kralikiene
- Institute of Biosciences, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Neringa Daugelaviciene
- VU LSC-EMBL Partnership for Genome Editing Technologies, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Urte Neniskyte
- Institute of Biosciences, Life Sciences Center, Vilnius University, Vilnius, Lithuania
- VU LSC-EMBL Partnership for Genome Editing Technologies, Life Sciences Center, Vilnius University, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Natasa Giedraitiene
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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Ter Horst L, van Zeggeren IE, Olie SE, van de Beek D, Brouwer MC. Predictors of unfavourable outcome in adults with suspected central nervous system infections: a prospective cohort study. Sci Rep 2023; 13:21250. [PMID: 38040800 PMCID: PMC10692224 DOI: 10.1038/s41598-023-48472-z] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
Suspected central nervous system (CNS) infections may pose a diagnostic challenge, and often concern severely ill patients. We aim to identify predictors of unfavourable outcome to prioritize diagnostics and treatment improvements. Unfavourable outcome was assessed on the Glasgow Outcome Scale at hospital discharge, defined by a score of 1 to 4. Of the 1152 episodes with suspected CNS infection, from two Dutch prospective cohorts, the median age was 54 (IQR 37-67), and 563 episodes (49%) occurred in women. The final diagnoses were categorized as CNS infection (N = 358 episodes, 31%), CNS inflammatory disease (N = 113, 10%), non-infectious non-inflammatory neurological disorder (N = 388, 34%), non-neurological infection (N = 252, 22%), and other systemic disorder (N = 41, 4%). Unfavourable outcome occurred in 412 of 1152 (36%), and 99 died (9%). Predictors for unfavourable outcomes included advanced age, absence of headache, tachycardia, altered mental state, focal cerebral deficits, cranial nerve palsies, low thrombocytes, high CSF protein, and the final diagnosis of CNS inflammatory disease (odds ratio 4.5 [95% confidence interval 1.5-12.6]). Episodes suspected of having a CNS infection face high risk of experiencing unfavourable outcome, stressing the urgent need for rapid and accurate diagnostics. Amongst the suspected CNS infection group, those diagnosed with CNS inflammatory disease have the highest risk.
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Affiliation(s)
- Liora Ter Horst
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Ingeborg E van Zeggeren
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Sabine E Olie
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands.
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Al-Mekhlafi A, Waqas FH, Krueger M, Klawonn F, Akmatov MK, Müller-Vahl K, Trebst C, Skripuletz T, Stangel M, Sühs KW, Pessler F. Elevated phospholipids and acylcarnitines C4 and C5 in cerebrospinal fluid distinguish viral CNS infections from autoimmune neuroinflammation. J Transl Med 2023; 21:776. [PMID: 37919735 PMCID: PMC10621113 DOI: 10.1186/s12967-023-04637-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/16/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Viral and autoimmune encephalitis may present with similar symptoms, but require different treatments. Thus, there is a need for biomarkers to improve diagnosis and understanding of pathogenesis. We hypothesized that virus-host cell interactions lead to different changes in central nervous system (CNS) metabolism than autoimmune processes and searched for metabolite biomarkers in cerebrospinal fluid (CSF) to distinguish between the two conditions. METHODS We applied a targeted metabolomic/lipidomic analysis to CSF samples from patients with viral CNS infections (n = 34; due to herpes simplex virus [n = 9], varicella zoster virus [n = 15], enteroviruses [n = 10]), autoimmune neuroinflammation (n = 25; autoimmune anti-NMDA-receptor encephalitis [n = 8], multiple sclerosis [n = 17), and non-inflamed controls (n = 31; Gilles de la Tourette syndrome [n = 20], Bell's palsy with normal CSF cell count [n = 11]). 85 metabolites passed quality screening and were evaluated as biomarkers. Standard diagnostic CSF parameters were assessed for comparison. RESULTS Of the standard CSF parameters, the best biomarkers were: CSF cell count for viral infections vs. controls (area under the ROC curve, AUC = 0.93), Q-albumin for viral infections vs. autoimmune neuroinflammation (AUC = 0.86), and IgG index for autoimmune neuroinflammation vs. controls (AUC = 0.90). Concentrations of 2 metabolites differed significantly (p < 0.05) between autoimmune neuroinflammation and controls, with proline being the best biomarker (AUC = 0.77). In contrast, concentrations of 67 metabolites were significantly higher in viral infections than controls, with SM.C16.0 being the best biomarker (AUC = 0.94). Concentrations of 68 metabolites were significantly higher in viral infections than in autoimmune neuroinflammation, and the 10 most accurate metabolite biomarkers (AUC = 0.89-0.93) were substantially better than Q-albumin (AUC = 0.86). These biomarkers comprised six phosphatidylcholines (AUC = 0.89-0.92), two sphingomyelins (AUC = 0.89, 0.91), and acylcarnitines isobutyrylcarnitine (C4, AUC = 0.92) and isovalerylcarnitine (C5, AUC = 0.93). Elevated C4 and C5 concentrations suggested dysfunctional mitochondrial β-oxidation and correlated only moderately with CSF cell count (Spearman ρ = 0.41 and 0.44), indicating that their increase is not primarily driven by inflammation. CONCLUSIONS Changes in CNS metabolism differ substantially between viral CNS infections and autoimmune neuroinflammation and reveal CSF metabolites as pathophysiologically relevant diagnostic biomarkers for the differentiation between the two conditions. In viral CNS infections, the observed higher concentrations of free phospholipids are consistent with disruption of host cell membranes, whereas the elevated short-chain acylcarnitines likely reflect compromised mitochondrial homeostasis and energy generation.
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Affiliation(s)
- Amani Al-Mekhlafi
- Biostatistics, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Fakhar H Waqas
- Research Group Biomarkers for Infectious Diseases, TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany
| | - Maike Krueger
- Research Group Biomarkers for Infectious Diseases, TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany
| | - Frank Klawonn
- Biostatistics, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | | | - Kirsten Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Translational Medicine, Novartis Institute for Biomedical Research, Basel, Switzerland
| | | | - Frank Pessler
- Biostatistics, Helmholtz Centre for Infection Research, Braunschweig, Germany.
- Research Group Biomarkers for Infectious Diseases, TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany.
- Centre for Individualised Infection Medicine, Hannover, Germany.
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Bloch KC, Glaser C, Gaston D, Venkatesan A. State of the Art: Acute Encephalitis. Clin Infect Dis 2023; 77:e14-e33. [PMID: 37485952 DOI: 10.1093/cid/ciad306] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 07/25/2023] Open
Abstract
Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.
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Affiliation(s)
- Karen C Bloch
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Glaser
- California Department of Public Health, Richmond, California, USA
| | - David Gaston
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
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Le Maréchal M, Diaz-Arias LA, Beekmann SE, Polgreen P, Messacar K, Tunkel AR, Thakur KT, Venkatesan A. Perspectives on Diagnosis and Management of All-Cause Encephalitis: A National Survey of Adult Infectious Diseases Physicians. Open Forum Infect Dis 2023; 10:ofad132. [PMID: 37125234 PMCID: PMC10135423 DOI: 10.1093/ofid/ofad132] [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: 12/16/2022] [Accepted: 03/16/2023] [Indexed: 05/02/2023] Open
Abstract
Background Encephalitis is widely recognized as a challenging condition to diagnose and manage. The care of patients with encephalitis typically involves multiple disciplines, including neurologists and infectious disease (ID) physicians. Our objective was to describe the perspectives and needs of ID physicians regarding encephalitis, using a cross-sectional questionnaire survey. Methods We performed a survey among physician members of the Infectious Diseases Society of America's (IDSA) Emerging Infections Network (EIN). Results Response rate was 33% (480 among 1472 active EIN physician members). More than 75% of respondents reported caring for patients with suspected encephalitis. Although one-third were involved in the care of multiple patients with autoimmune encephalitis (AE) annually, comfort in diagnosing and managing encephalitis, and in particular AE, was low. Experience with advanced diagnostic tools was variable, as were approaches toward deployment of such tools. Respondents noted that training could be improved by incorporating a multidisciplinary approach taking advantage of online and virtual platforms. ID physicians report a heavy reliance on the 2008 IDSA guidelines for the management of encephalitis, and indicated strong support for a formal update. Conclusions ID physicians play an important role in the diagnosis and management of all-cause encephalitis. Despite exposure to AE, few ID physicians are comfortable in recognizing, diagnosing, and treating AE. Moreover, comfort with and use of advanced diagnostic tools for infectious encephalitis was highly variable. Training in encephalitis should include a focus on use and stewardship of advanced diagnostic tools and on collaborative approaches with neurologists and other practitioners on mechanisms and clinical presentations of AE. There is a need for a formal update of 2008 guidelines on the management of encephalitis.
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Affiliation(s)
- Marion Le Maréchal
- Correspondence: Marion Le Maréchal, MD, PhD, CHU Grenoble-Alpes, Boulevard de la chantourne, 38700 La Tronche, France (); Arun Venkatesan, MD, PhD, Neurology Department, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287 ()
| | | | - Susan E Beekmann
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Philip Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Allan R Tunkel
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Arun Venkatesan
- Correspondence: Marion Le Maréchal, MD, PhD, CHU Grenoble-Alpes, Boulevard de la chantourne, 38700 La Tronche, France (); Arun Venkatesan, MD, PhD, Neurology Department, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287 ()
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Gaspard N. Stop Being So Negative: Favorable Outcome and Response to Immune Therapies in Antibody-Negative Probable Autoimmune Encephalitis. Epilepsy Curr 2023; 23:35-37. [PMID: 36923336 PMCID: PMC10009127 DOI: 10.1177/15357597221137417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Seronegative Autoimmune Encephalitis: Clinical Characteristics and Factors Associated With Outcomes Lee WJ, Lee HS, Kim DY, Lee HS, Moon J, Park KI, Lee SK, Chu K, Lee ST. Brain. 2022;145(10):3509-3521. doi:10.1093/brain/awac166 Seronegative autoimmune encephalitis is autoimmune encephalitis without any identifiable pathogenic antibody. Although it is a major subtype of autoimmune encephalitis, many unmet clinical needs exist in terms of clinical characteristics, treatments and prognosis. In this institutional cohort study, patients diagnosed with seronegative autoimmune encephalitis with available 2-year outcomes were analysed for the disease course, 2-year outcome prediction system, effect of immunotherapy, necessity of further immunotherapy at 6 or 12 months and pattern of brain atrophy. Seronegative autoimmune encephalitis was subcategorized into antibody-negative probable autoimmune encephalitis, autoimmune limbic encephalitis and acute disseminated encephalomyelitis. Poor 2-year outcome was defined by modified Rankin scale scores 3–6, and the 2-year serial data of Clinical Assessment Scales in Autoimmune Encephalitis score was used for longitudinal data analyses. A total of 147 patients were included. The frequency of achieving a good 2-year outcome (modified Rankin scale 0–2) was 56.5%. The antibody-negative probable autoimmune encephalitis subtype exhibited the poorest outcomes, although the baseline severity was similar among the subtypes. The RAPID score, consisting of five early usable clinical factors, refractory status epilepticus, age of onset ≥60 years, probable autoimmune encephalitis (antibody-negative probable autoimmune encephalitis subtype), infratentorial involvement and delay of immunotherapy ≥1 month, was associated with poorer 2-year outcomes. Any immunotherapy was associated with clinical improvement in the patients with low risk for poor 2-year outcomes (RAPID scores 0–1), and the combination immunotherapy of steroid, immunoglobulin, rituximab and tocilizumab was associated with better outcomes in the patients with high risk for poor 2-year outcomes (RAPID scores 2–5). In patients with persistent disease at 6 months, continuing immunotherapy was associated with more improvement, while the effect of continuing immunotherapy for more than 12 months was unclear. In the longitudinal analysis of MRI, the development of cerebellar atrophy indicated poor outcomes, while the absence of diffuse cerebral atrophy or medial temporal atrophy indicated the possibility of a good outcome. This study provides information about the clinical characteristics and courses, the effect of immunotherapy and its duration, and prognostic factors in seronegative autoimmune encephalitis.
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