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Beutler BD, Moody AE, Thomas JM, Sugar BP, Ulanja MB, Antwi-Amoabeng D, Tsikitas LA. Anti-N-methyl-D-aspartate receptor-associated encephalitis: A review of clinicopathologic hallmarks and multimodal imaging manifestations. World J Radiol 2024; 16:1-8. [PMID: 38312349 PMCID: PMC10835429 DOI: 10.4329/wjr.v16.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/04/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
Anti-N-methyl-D-aspartate receptor-associated encephalitis (NMDARE) is a rare immune-mediated neuroinflammatory condition characterized by the rapid onset of neuropsychiatric symptoms and autonomic dysfunction. The mechanism of pathogenesis remains incompletely understood, but is thought to be related to antibodies targeting the GluN1 subunit of the NMDA receptor with resultant downstream dysregulation of dopaminergic pathways. Young adults are most frequently affected; the median age at diagnosis is 21 years. There is a strong female predilection with a female sex predominance of 4:1. NMDARE often develops as a paraneoplastic process and is most commonly associated with ovarian teratoma. However, NMDARE has also been described in patients with small cell lung cancer, clear cell renal carcinoma, and other benign and malignant neoplasms. Diagnosis is based on correlation of the clinical presentation, electroencephalography, laboratory studies, and imaging. Computed tomography, positron emission tomography, and magnetic resonance imaging are essential to identify an underlying tumor, exclude clinicopathologic mimics, and predict the likelihood of long-term functional impairment. Nuclear imaging may be of value for prognostication and to assess the response to therapy. Treatment may involve high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange. Herein, we review the hallmark clinicopathologic features and imaging findings of this rare but potentially devastating condition and summarize diagnostic criteria, treatment regimens, and proposed pathogenetic mechanisms.
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Affiliation(s)
- Bryce David Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Alastair E Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84132, United States
| | - Jerry Mathew Thomas
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Benjamin Phillip Sugar
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Mark B Ulanja
- Department of Internal Medicine, Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70601, United States
| | - Daniel Antwi-Amoabeng
- Department of Internal Medicine, Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70601, United States
| | - Lucas Anthony Tsikitas
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
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Diagnostic Value of Structural and Functional Neuroimaging in Autoimmune Epilepsy. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:8894213. [PMID: 33380947 PMCID: PMC7752299 DOI: 10.1155/2020/8894213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Epilepsy is a common nervous system disease, which affects about 70 million people all over the world. In 2017, the International League Against Epilepsy (ILAE) considered immune factors as its independent cause, and the concept of autoimmune epilepsy (AE) was widely accepted. Early diagnosis and timely treatment can effectively improve the prognosis of the disease. However, due to the diversity of clinical manifestations, the expensive cost of autoantibody detection, and the increased prevalence in Western China, the difficulty for clinicians in early diagnosis and treatment has increased. Fortunately, convenient and fast imaging examinations are expected to help even more. The imaging manifestations of AE patients were characteristic, especially the combined application of structural and functional neuroimaging, which improved the diagnostic value of imaging. In this paper, several common autoantibodies associated with AE and their structure and function changes in neuroimaging were reviewed to provide help for neurologists to achieve the goal of precision medicine.
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EEG analysis in anti-NMDA receptor encephalitis: Description of typical patterns. Clin Neurophysiol 2019; 130:289-296. [DOI: 10.1016/j.clinph.2018.10.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/22/2018] [Accepted: 10/16/2018] [Indexed: 01/21/2023]
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Early identification of anti-NMDA receptor encephalitis presenting cerebral lesions in unconventional locations on magnetic resonance imaging. J Neuroimmunol 2018; 320:101-106. [DOI: 10.1016/j.jneuroim.2018.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/25/2018] [Accepted: 03/25/2018] [Indexed: 11/24/2022]
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Vogrig A, Joubert B, Ducray F, Thomas L, Izquierdo C, Decaestecker K, Martinaud O, Gerardin E, Grand S, Honnorat J. Glioblastoma as differential diagnosis of autoimmune encephalitis. J Neurol 2018; 265:669-677. [PMID: 29383516 DOI: 10.1007/s00415-018-8767-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 11/13/2017] [Accepted: 01/23/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the clinical and radiological features that should raise suspicion for the autoimmune encephalitis (AE)-like presentation of glioblastoma. METHODS This is an observational, retrospective case series of patients referred to the French National Reference Center on Paraneoplastic Neurological Diseases for suspected AE (possible, probable or definite, using the 2016 criteria) who later received a final diagnosis of glioblastoma according to 2016 WHO criteria. An extensive literature search was also conducted for similar existing cases. RESULTS Between 2014 and 2016, 306 patients were referred to our center for suspected AE. Six of these patients (2%) later developed pathologically confirmed glioblastoma. Thirteen patients (9 male) were included for analysis (6 from the present series and 7 from the literature); median age was 63. Initially, a diagnosis of AE was clinically suspected based on: working memory deficits (77%), seizures (62%) (including status epilepticus in 23%), and psychiatric symptoms (46%). Initial brain MRI was not in favor of a typical glioblastoma pattern and showed bilateral (54%) or unilateral selective limbic involvement. Five patients exhibited initial slight contrast enhancement. A clear inflammatory CSF was present in five patients and three from the literature showed autoantibody positivity (NMDAR, VGKC, GluRepsilon2). Median delay between suspicions of AE to GBM diagnosis was 3 months (range 1.5-24) and one patient from the literature was diagnosed post-mortem. CONCLUSIONS An alternative diagnosis of glioblastoma should be considered in patients presenting initially as AE, especially in patients who do not fulfill the criteria for definite AE and in those with a poor clinical evolution despite initial improvement.
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Affiliation(s)
- Alberto Vogrig
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Francois Ducray
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Laure Thomas
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Cristina Izquierdo
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | | | - Olivier Martinaud
- Department of Neurology, Rouen University Hospital, Rouen, France
- Normandie Univ, UNICAEN, EPHE, INSERM, U1077, CHU de Caen, Neuropsychologie et Imagerie de la Mémoire Humaine, Caen, France
| | - Emmanuel Gerardin
- Department of Neuroradiology, Rouen University Hospital, Rouen, France
| | - Sylvie Grand
- Department of Neuroradiology, Grenoble University Hospital, Grenoble, France
| | - Jérome Honnorat
- French Reference Center of Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Lyon, France.
- Synatac Team, NeuroMyoGene Institut, INSERM U1217/CNRS, UMR5310, Lyon, France.
- University Claude Bernard Lyon 1, Lyon, France.
- Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique, Hôpital Neurologique, 59 Boulevard Pinel, 69677, Bron Cedex, France.
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Gera A, Kamson DO, Villaflor VM, Lukas RV. Added diagnostic utility of PET in a patient with subacute encephalopathy and small-cell lung cancer. Lung Cancer Manag 2017; 6:9-16. [PMID: 30643565 DOI: 10.2217/lmt-2016-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/12/2017] [Indexed: 11/21/2022] Open
Abstract
Diagnosis of paraneoplastic neurologic disorder (PND) synthesizes the clinical picture (including the temporal relationship to the cancer diagnosis), detection of onconeural antibodies and exclusion of alternative causes. The mainstay of brain imaging of PNDs is MRI. There is also an increasingly recognized role of PET using radiotracer 18F-Fluorodeoxyglucose (FDG) in the evaluation of the brain. We describe a 67-year-old female with a 50-year smoking history and small-cell lung cancer developing subacute encephalopathy with MRI and PET abnormalities identifying paraneoplastic encephalitis. PET may complement conventional tools in diagnosing a subset of patients with PND.
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Affiliation(s)
- Anjali Gera
- Department of Neurology, University of Chicago, Chicago, Illinois, USA.,Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - David Olayinka Kamson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA.,Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Victoria M Villaflor
- Section of Hematology & Oncology, Northwestern University, Chicago, Illinois, USA.,Section of Hematology & Oncology, Northwestern University, Chicago, Illinois, USA
| | - Rimas V Lukas
- Department of Neurology, University of Chicago, Chicago, Illinois, USA.,Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Sudan YS, Vinayan KP, Roy AG, Wagh A, Kannoth S, Patil S. Clinical Characteristics and Follow-up of South Indian Children with Autoimmune Encephalopathy. Indian J Pediatr 2016; 83:1367-1373. [PMID: 27086607 DOI: 10.1007/s12098-016-2092-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 03/10/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the clinical characteristics of a cohort of south Indian children with probable autoimmune encephalopathy from a tertiary care academic hospital and to compare this data with the existing literature. METHODS Patients with encephalopathy plus one or more of neuropsychiatric symptoms, seizures, movement disorder or cognitive dysfunction were identified. Common infectious causes were excluded. Clinical characteristics, investigations, management and outcome were analyzed. RESULTS Thirteen patients were included in the study; 12 were females (92.3 %) and mean age was 9.6 y. Most common presentation was behavior change (13 patients) followed by seizures (11 patients). Three patients showed lymphocytic pleocytosis in CSF and one patient had oligoclonal bands. Initial MRI was normal in all patients except in one. Most common EEG abnormality was mild background slowing. Only one child had ovarian tumor. S.NMDA receptor antibody was positive in 10 patients (83 %), and all of them received immunotherapy. Six out of 13 children were followed up for more than 1 y (mean - 21 mo). Recurrence was noted in 4 out of 6 patients (66 %). On last follow-up, good recovery was seen in 2 children (33 %), moderate disability in 3 (50 %) and severe disability in 1 (16 %). CONCLUSIONS The clinical characteristics and outcome of one of the largest single center cohort of Indian children with autoimmune encephalopathy is reported. Autoimmune encephalopathy should be considered as a differential diagnosis in the acute and subacute encephalopathies of childhood and treating pediatrician should be aware of this entity.
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Affiliation(s)
- Yeeshu Singh Sudan
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India
| | - K P Vinayan
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India.
| | - Arun Grace Roy
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India
| | - Amarjeet Wagh
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India
| | - Sudheeran Kannoth
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India
| | - Sandeep Patil
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, India
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Lagarde S, Lepine A, Caietta E, Pelletier F, Boucraut J, Chabrol B, Milh M, Guedj E. Cerebral (18)FluoroDeoxy-Glucose Positron Emission Tomography in paediatric anti N-methyl-D-aspartate receptor encephalitis: A case series. Brain Dev 2016; 38:461-70. [PMID: 26542469 DOI: 10.1016/j.braindev.2015.10.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/15/2015] [Accepted: 10/20/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a frequent and severe cause of encephalitis in children with potential efficient treatment (immunotherapy). Suggestive clinical features are behavioural troubles, seizures and movement disorders. Prompt diagnosis and treatment initiation are needed to guarantee favourable outcome. Nevertheless, diagnosis may be challenging because of the classical ancillary test (magnetic resonance imaging (MRI), electroencephalogram, standard cerebro-spinal fluid analysis) have limited sensitivity. Currently, immunological analyses are needed for the diagnostic confirmation. In adult patients, some studies suggested a potential role of cerebral (18)FluoroDeoxy-Glucose Positron Emission Tomography (FDG-PET) in the evaluation of anti-NMDAR encephalitis. Nevertheless, almost no data exist in paediatric population. METHOD We report retrospectively clinical, ancillary tests and cerebral FDG-PET data in 6 young patients (median age=10.5 years, 4 girls) with immunologically confirmed anti-NMDAR encephalitis. RESULTS Our patients presented classical clinical features of anti-NMDAR encephalitis with severe course (notably four patients had normal MRI). Our series shows the feasibility and the good sensitivity of cerebral FDG-PET (6/6 patients with brain metabolism alteration) in paediatric population. We report some particular features in this population: extensive, symmetric cortical hypometabolism especially in posterior areas; asymmetric anterior focus of hypermetabolism; and basal ganglia hypermetabolism. We found also a good correlation between the clinical severity and the cerebral metabolism changes. Moreover, serial cerebral FDG-PET showed parallel brain metabolism and clinical improvement. CONCLUSION Our study reveals the existence of specific patterns of brain metabolism alteration in anti-NMDAR encephalitis in paediatric population.
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Affiliation(s)
- Stanislas Lagarde
- APHM, Timone Hospital, Paediatric Neurology Department, 13005 Marseille, France.
| | - Anne Lepine
- APHM, Timone Hospital, Paediatric Neurology Department, 13005 Marseille, France
| | - Emilie Caietta
- APHM, Timone Hospital, Paediatric Neurology Department, 13005 Marseille, France
| | | | - José Boucraut
- Aix Marseille Université, CNRS, CRN2M UMR 7286, 13344 Marseille, France
| | - Brigitte Chabrol
- APHM, Timone Hospital, Paediatric Neurology Department, 13005 Marseille, France
| | - Mathieu Milh
- APHM, Timone Hospital, Paediatric Neurology Department, 13005 Marseille, France
| | - Eric Guedj
- APHM, Timone Hospital, Nuclear Medicine Department, 13005 Marseille, France
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Endres D, Perlov E, Stich O, Rauer S, Maier S, Waldkircher Z, Lange T, Mader I, Meyer PT, Tebartz van Elst L. Hypoglutamatergic state is associated with reduced cerebral glucose metabolism in anti-NMDA receptor encephalitis: a case report. BMC Psychiatry 2015; 15:186. [PMID: 26231521 PMCID: PMC4522073 DOI: 10.1186/s12888-015-0552-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/06/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis was first described in 2005 in association with ovarian teratoma. The diagnostic workup of this common autoimmune encephalitis includes cerebrospinal fluid analysis, electroencephalography, magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (FDG-PET). In addition to standard diagnostics, we performed metabolic investigations using proton magnet resonance spectroscopy ((1)H-MRS). CASE PRESENTATION We describe the case of a non-limbic anti-NMDAR encephalitis with a long course of disease (21 months). Laboratory diagnostics showed antibodies against NMDAR; an MRI revealed unspecific findings. (1)H-MRS indicated a hypoglutamatergic state in the left prefrontal cortex associated with a left hemispherical hypometabolism on FDG-PET. Despite the long course of disease, immunosuppressive therapy with methylprednisolone and azathioprine led to almost complete remission of clinical symptoms. Clinical improvement developed in parallel with remarkable normalization of cerebral glucose metabolism on FDG-PET. CONCLUSION This case of long-lasting extra-limbic anti-NMDAR encephalitis is of high clinical relevance. First, it illustrates that a very good outcome is possible even if adequate therapy is started only 21 months after the onset of severe symptoms. Second, it provides valuable insights into the pathophysiology of such anti-NMDAR encephalitis; these insights prove that anti-NMDAR encephalitis is linked not only to hyperglutamatergic signals but also to hypoglutamatergic states. These findings, contradictory at first glance, can be integrated within the model of excitatory/inhibitory imbalance and local area network inhibition.
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Affiliation(s)
- Dominique Endres
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Evgeniy Perlov
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Oliver Stich
- Department of Neurology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Sebastian Rauer
- Department of Neurology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Simon Maier
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Zora Waldkircher
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany.
| | - Thomas Lange
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Irina Mader
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Philipp Tobias Meyer
- Department of Nuclear Medicine, University Medical Center Freiburg, Hugstetter Str. 64, 79106, Freiburg, Germany.
| | - Ludger Tebartz van Elst
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104 Freiburg, Germany ,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
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Lee EM, Kang JK, Oh JS, Kim JS, Shin YW, Kim CY. 18F-Fluorodeoxyglucose Positron-Emission Tomography Findings with Anti-N-Methyl-D-Aspartate Receptor Encephalitis that Showed Variable Degrees of Catatonia: Three Cases Report. J Epilepsy Res 2014; 4:69-73. [PMID: 25625091 PMCID: PMC4295056 DOI: 10.14581/jer.14014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 08/14/2014] [Indexed: 12/13/2022] Open
Abstract
Catatonia is one of the main symptoms of anti-N-Methyl-D-aspartate receptor (NMDAR) encephalitis. However, it is unknown whether metabolic changes observed with (18)F-Fluorodeoxyglucose positron-emission tomography (FDG-PET) are correlated with the severity of the catatonic symptoms and clinical course. Three patients with anti-NMDAR encephalitis showing variable degrees of catatonia were performed with FDG-PET scans during the acute and recovery phase. PET findings showed hypermetabolism in the frontotemporoparietal regions and bilateral basal ganglia in the patient with mild catatonia, but more widespread hypermetabolic regions including the thalamus and brainstem were observed in the patients with more severe catatonia. Follow-up PET scans in one patient showed mild hypermetabolism in the right basal ganglia that correlated with mild rigidity and tonic posturing in the left extremities. Extent of cerebral metabolic changes correlates with the severity of catatonia accompanied by behavioural, motor, autonomic, and breathing abnormalities in anti-NMDAR encephalitis.
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Affiliation(s)
- Eun Mi Lee
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Joong Koo Kang
- Departments of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungsu S Oh
- Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Kim
- Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Wook Shin
- Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Yoon Kim
- Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Anti–NMDA Receptor Encephalitis Associated With Transient Cerebral Dyschromatopsia, Prosopagnosia, and Lack of Stereopsis. J Neuroophthalmol 2014; 34:144-8. [DOI: 10.1097/wno.0000000000000117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol 2011; 10:63-74. [PMID: 21163445 DOI: 10.1016/s1474-4422(10)70253-2] [Citation(s) in RCA: 1568] [Impact Index Per Article: 120.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since its discovery in 2007, the encephalitis associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR) has entered the mainstream of neurology and other disciplines. Most patients with anti-NMDAR encephalitis develop a multistage illness that progresses from psychosis, memory deficits, seizures, and language disintegration into a state of unresponsiveness with catatonic features often associated with abnormal movements, and autonomic and breathing instability. The disorder predominantly affects children and young adults, occurs with or without tumour association, and responds to treatment but can relapse. The presence of a tumour (usually an ovarian teratoma) is dependent on age, sex, and ethnicity, being more frequent in women older than 18 years, and slightly more predominant in black women than it is in white women. Patients treated with tumour resection and immunotherapy (corticosteroids, intravenous immunoglobulin, or plasma exchange) respond faster to treatment and less frequently need second-line immunotherapy (cyclophosphamide or rituximab, or both) than do patients without a tumour who receive similar initial immunotherapy. More than 75% of all patients have substantial recovery that occurs in inverse order of symptom development and is associated with a decline of antibody titres. Patients' antibodies cause a titre-dependent, reversible decrease of synaptic NMDAR by a mechanism of crosslinking and internalisation. On the basis of models of pharmacological or genetic disruption of NMDAR, these antibody effects reveal a probable pathogenic relation between the depletion of receptors and the clinical features of anti-NMDAR encephalitis.
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Affiliation(s)
- Josep Dalmau
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Chan SHS, Wong VCN, Fung CW, Dale RC, Vincent A. Anti-NMDA receptor encephalitis with atypical brain changes on MRI. Pediatr Neurol 2010; 43:274-8. [PMID: 20837307 DOI: 10.1016/j.pediatrneurol.2010.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 03/17/2010] [Accepted: 05/03/2010] [Indexed: 10/19/2022]
Abstract
A young girl with antibodies to the N-methyl-D-aspartate receptor presented with a clinical syndrome suggestive of dyskinetic encephalitis lethargica with neuropsychiatric features at presentation, movement disorder, mutism, sleep disorder, and seizures. Persistent lesions in the white matter and pons were observed in magnetic resonance imaging of the brain, findings that have not been described previously in N-methyl-D-aspartate receptor antibody encephalitis.
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Affiliation(s)
- Sophelia H S Chan
- Division of Child Neurology/Developmental Paediatrics/Neurohabilitation, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
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Moscato EH, Jain A, Peng X, Hughes EG, Dalmau J, Balice-Gordon RJ. Mechanisms underlying autoimmune synaptic encephalitis leading to disorders of memory, behavior and cognition: insights from molecular, cellular and synaptic studies. Eur J Neurosci 2010; 32:298-309. [PMID: 20646055 DOI: 10.1111/j.1460-9568.2010.07349.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recently, several novel, potentially lethal and treatment-responsive syndromes that affect hippocampal and cortical function have been shown to be associated with auto-antibodies against synaptic antigens, notably glutamate or GABA-B receptors. Patients with these auto-antibodies, sometimes associated with teratomas and other neoplasms, present with psychiatric symptoms, seizures, memory deficits and decreased levels of consciousness. These symptoms often improve dramatically after immunotherapy or tumor resection. Here we review studies of the cellular and synaptic effects of these antibodies in hippocampal neurons in vitro and preliminary work in rodent models. Our work suggests that patient antibodies lead to rapid and reversible removal of neurotransmitter receptors from synaptic sites, leading to changes in synaptic and circuit function that in turn are likely to lead to behavioral deficits. We also discuss several of the many questions raised by these and related disorders. Determining the mechanisms underlying these novel anti-neurotransmitter receptor encephalopathies will provide insights into the cellular and synaptic bases of the memory and cognitive deficits that are hallmarks of these disorders, and potentially suggest avenues for therapeutic intervention.
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Affiliation(s)
- Emilia H Moscato
- Department of Neuroscience, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6074, USA
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Llorens V, Gabilondo I, Gómez-Esteban JC, Agundez M, Mendibe M, Bergara JC, Ciordia R, Saiz A, Zarranz JJ. Abnormal multifocal cerebral blood flow on Tc-99m HMPAO SPECT in a patient with anti-NMDA-receptor encephalitis. J Neurol 2010; 257:1568-9. [PMID: 20352245 DOI: 10.1007/s00415-010-5546-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Revised: 03/10/2010] [Accepted: 03/12/2010] [Indexed: 01/17/2023]
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