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Bandeira GG, Barreto Lima PLGDS, Araújo DABS, Pinheiro MSN, Albuquerque Mota LD, Simão RM, de Carvalho FMO, Vazquez FD, de Vasconcelos Gama VC, de Queiroz DC, da Fonseca Lira MZR, de Oliveira Júnior PH, Guimarães Junior FA, Caminha GC, de Figueiredo Santos C, Sobreira-Neto MA, Braga-Neto P, Silva GD, Nóbrega PR. Controversies in immunotherapy for anti-NMDA receptor encephalitis: a scoping review with a proposal of operational definitions. Neurol Sci 2023; 44:4307-4312. [PMID: 37597088 DOI: 10.1007/s10072-023-07018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Anti-NMDA receptor encephalitis (NMDARE), an autoimmune encephalitis associated with autoantibodies against the N-methyl-D-aspartate (NMDA) receptor, affects predominantly young women and is associated with psychiatric symptoms, seizures, movement disorders, and autonomic instability. Traditional treatments of anti-NMDA receptor encephalitis involve corticosteroids, intravenous immunoglobulin, plasmapheresis, cyclophosphamide, and rituximab. However, many controversies remain in the treatment for NMDA receptor encephalitis, such as optimal timing and combination of different immunotherapies, the role of newer strategies (e.g., bortezomib or tocilizumab) for severe and refractory patients, and the need or not for long-term immunosuppression. Our goal was to perform a scoping review to discuss the controversial topics of immunotherapy for NMDA receptor encephalitis and propose operational definitions to guide clinical practice and future research in the field.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carolina de Figueiredo Santos
- Universidade de Fortaleza, Ceara, Fortaleza, Brazil
- Hospital Infantil Albert Sabin, Ceara, Fortaleza, Brazil
- Núcleo de Tratamento e Estimulação Precoce, Federal University of Ceara, Fortaleza, Brazil
| | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Fortaleza, Brazil
| | - Guilherme Diogo Silva
- Division of Neurology, Hospital of Clinics, University of São Paulo, São Paulo, Brazil
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Siriratnam P, McArthur L, Chen Z, Kempster P, Monif M. Movement disorders in cell surface antibody mediated autoimmune encephalitis: a meta-analysis. Front Neurol 2023; 14:1225523. [PMID: 37545714 PMCID: PMC10401600 DOI: 10.3389/fneur.2023.1225523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Background Autoimmune encephalitis (AE) is an increasingly recognized neuroinflammatory disease entity in which early detection and treatment leads to the best clinical outcomes. Movement disorders occur in AE but their characteristics are not well defined. Objectives To identify the frequency, classification, and prognostic significance of movement disorders in AE. Methods We conducted a systematic review and random-effects meta-analysis of movement disorders in cell surface antibody mediated AE. The frequency of any movement disorder as well as the classification of movement disorders in AE serotypes was determined. We looked at adults 18 years and older and included publications that described at least 10 cases. We used the following four electronic databases: Medline (Ovid), EMBASE (Ovid), APA Psychinfo, and Cochrane library. Results A total of 1,192 titles and abstracts were reviewed. Thirty-seven studies were included in the final meta-analysis. At least one kind of movement disorder was present in 40% of the entire AE cohort, 53% with anti-NMDA receptor antibodies, 33% with anti-CASPR2 antibodies, 30% with anti-LGI1 antibodies and 13% with anti-GABA receptor antibodies. Dyskinesia was the commonest movement disorder in anti-NMDA antibody mediated AE and faciobrachial dystonic seizures were most frequent in anti-LGI1 antibody mediated AE. Patients with a movement disorder tended to have a higher mortality. The risk of bias in the included studies was mostly moderate or high. Conclusion Movement disorders are common in AE and their identification, in conjunction with other clinical and paraclinical features, may facilitate earlier diagnosis. The prognostic implications of movement disorders in AE warrant further dedicated study. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42023386920.
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Affiliation(s)
- Pakeeran Siriratnam
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology, Alfred Health, Melbourne, VIC, Australia
| | | | - Zhibin Chen
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter Kempster
- Neurosciences Department, Monash Medical Centre, Clayton, VIC, Australia
- School of Clinical Sciences of Medicine, Monash University, Clayton, VIC, Australia
| | - Mastura Monif
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
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Pointon T, Ward R, Yeshokumar A, Piquet A, Schreiner T, Kammeyer R. Evaluation of multiple consensus criteria for autoimmune encephalitis and temporal analysis of symptoms in a pediatric encephalitis cohort. Front Neurol 2022; 13:952317. [PMID: 36237630 PMCID: PMC9552833 DOI: 10.3389/fneur.2022.952317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the sensitivity and specificity of current criteria for the diagnosis of autoimmune encephalitis (AE) and the temporal onset of neuropsychiatric symptoms (NP) in a pediatric encephalitis cohort. Background Multiple criteria for AE have been developed, including the Graus and pediatric-focused Cellucci consensus criteria, and the Determining Etiology in Encephalitis (DEE) score for patients with encephalitis. Early identification and treatment of AE is crucial to improve outcomes, but this can be difficult given the frequent overlap of clinical presentation between AE and infectious encephalitis (IE). Design/methods A retrospective review was conducted of patients seen at our institution from 2000 to 2021 with a final diagnosis of AE or IE. These were narrowed through multiple exclusions to etiology-confirmed IE or antibody-positive/negative AE. Time of onset or results of all symptoms and diagnostics were recorded. Sensitivity and specificity of each criterion under various clinical scenarios were calculated over the first month after initial NP symptom onset. Results A total of 23 antibody-positive AE, 9 antibody-negative AE and 23 IE patients were included in final analysis. Under an idealized scenario with rapid initial diagnostic evaluations, the sensitivity for pediatric AE by day 28 after onset of NP symptoms approached 90% for both Cellucci and Graus criteria. Specificity within these 28 days was low without infectious testing results, increasing the greatest with rapid PCR testing and second with infectious antibody testing-reaching ~90% with both. A DEE score of 3 provided a specificity of 100% in identifying IE, but low sensitivity (29%). Symptoms were noted to cluster within several days of onset in IE, but in AE were spread out. Personality/behavioral change, speech change, affective disorder, and sleep disturbance were noted more often in AE, while fever, elevated C-reactive protein or CSF protein, and abnormal MRI-Brain occurred more often in IE. Conclusion In this study, we provide the first evaluation of the Cellucci criteria and the first validation of the DEE score in the differentiation of pediatric AE and IE. Further refinement of AE criteria is needed to improve early detection and treatment of pediatric AE.
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Affiliation(s)
- Tiffany Pointon
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ryan Ward
- School of Medicine, University of Colorado, Aurora, CO, United States
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Amanda Piquet
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Teri Schreiner
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ryan Kammeyer
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Neuroimmunology, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
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Yang R, Ge F, Jiang J, Wang Y, Wan M, Zhang W. Temporal rank of clinical characteristics and prognosis of anti-N-methyl-d-aspartate receptor encephalitis. Brain Behav 2021; 11:e2277. [PMID: 34232562 PMCID: PMC8413795 DOI: 10.1002/brb3.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/10/2021] [Accepted: 06/23/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Early recognition and intervention of patients with the anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis are important to achieve a better prognosis. The study aims to summarize the real-world perspectives of anti-NMDAR encephalitis patients in China via electronic medical records (EMRs). METHODS Using EMRs of patients from 2013 to 2019 from West China Hospital in China, a retrospective research was conducted to demonstrate the temporary rank of clinical characteristics and disease prognosis of anti-NMDAR encephalitis. The modified Rankin Scale (mRS) scores were used to divide the anti-NMDAR-encephalitis into two groups (poor prognosis vs. good prognosis). Chi-square test and logistic regression were used to analyze factors associated with prognosis. RESULTS Here, 78 patients were included. The most common clinical characteristics are cognitive dysfunction (86.0%) and thought disorder (86.0%). Cognitive dysfunction, thought disorder, and seizures tended to appear soon after prodrome symptoms. Logistics analysis results showed that cognitive dysfunction (OR = 4.48, 95% CI = 1.09-18.47), the score of (GCS ≤ 8) (OR = 4.52, 95% CI = 1.18-17.32), positive antibodies in serum (OR = 4.89, 95% CI = 1.19-20.13) and delay immunotherapy (OR = 4.76, 95% CI = 1.79-12.60) were risk factors of poor clinical outcomes. CONCLUSIONS There are two peaks in the development of autoimmune encephalitis (AE). The first peak is cognitive dysfunction, and the second peak is autonomic dysfunction. Cognitive dysfunction and GCS score ≤8 at admission, antibodies positive in serum, and delay immunotherapy were risk factors for a poor prognosis at discharge.
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Affiliation(s)
- Runnan Yang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fenfen Ge
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jingwen Jiang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yue Wang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mengtong Wan
- Wuyuzhuang Honors College, Sichuan University, Chengdu, Sichuan, China
| | - Wei Zhang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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