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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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Wada T, Mori H, Shindo K. Serial assessment of multimodality imaging in anti-leucine-rich glioma-inactivated 1 antibody encephalitis: A case report. eNeurologicalSci 2022; 29:100426. [PMID: 36161067 PMCID: PMC9494171 DOI: 10.1016/j.ensci.2022.100426] [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: 06/13/2022] [Revised: 07/29/2022] [Accepted: 09/10/2022] [Indexed: 11/29/2022] Open
Abstract
In autoimmune encephalitis, abnormalities of diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), arterial spin labeling (ASL) in magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) have been reported. However, there are few studies of long-term follow-up of imaging. We report a case of anti-leucine-rich glioma-inactivated 1 antibody encephalitis whose MRI (DWI, FLAIR and ASL), 99mTcHM-PAO SPECT (PAO-SPECT) and 18F-FDG-PET were evaluated through the clinical course. ASL, PAO-SPECT and 18F-FDG-PET consistently showed abnormalities in almost the same area. Serial assessment of these imaging modalities is useful in evaluating disease activity and efficacy of treatment. We followed up anti-LGI1 encephalitis by comparing multimodality imaging. ASL, PAO-SPECT and 18F-FDG-PET showed similar trends of abnormalities. Serial assessment of imaging was useful in evaluating disease activity.
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Affiliation(s)
- Takafumi Wada
- Department of Neurology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki/Okayama, 710-8602, Japan
| | - Hitoshi Mori
- Department of Neurology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki/Okayama, 710-8602, Japan
| | - Katsuro Shindo
- Department of Neurology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki/Okayama, 710-8602, Japan
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Yamada N, Kuki I, Hattori T, Yamamoto N, Nagase S, Nukui M, Inoue T, Okazaki S, Kawawaki H, Horino A, Sakuma H. Late relapse of anti-N-methyl-d-aspartate receptor encephalitis with amusia and transiently reduced uptake in 123I-iomazenil single-photon emission computed tomography. Brain Dev 2022; 44:558-561. [PMID: 35662527 DOI: 10.1016/j.braindev.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis has a high relapse rate at approximately 10-20%. Most relapses occur within 2 years from onset, and 5 years after onset is rare. We report a case of anti-NMDAR encephalitis relapse with amusia 10 years after the initial encephalitis and discuss the usefulness of 123I-iomazenil single-photon emission computerized tomography (IMZ-SPECT) for its diagnosis. CASE A 13-year-old left-handed girl presented with a depressed level of consciousness and focal to bilateral tonic-clonic seizures. Cerebrospinal fluid (CSF) analysis showed a mildly increased white blood cell count, elevated neopterin levels, and positive oligoclonal bands. Brain MRI was normal. IMZ-SPECT revealed reduced uptake in the right frontoparietal region. She received intravenous pulse methylprednisolone (IVMP) and high-dose intravenous immunoglobulin for autoimmune encephalitis; her symptoms resolved without neurological deficits. At 23 years old, she had mild right-sided numbness, dysarthria, amusia, and tonic-clonic seizures. Although the CSF analysis and brain MRI were normal, IMZ-SPECT revealed reduced uptake, indicating a relapse of encephalitis. IVMP administration resolved the symptoms. After discharge, the initial and relapse CSF analysis revealed anti-NMDAR antibodies. CONCLUSION An anti-NMDAR encephalitis relapse 10 years after onset has never been reported. IMZ-SPECT may help in the diagnosis of anti-NMDAR encephalitis.
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Affiliation(s)
- Naoki Yamada
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan.
| | - Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Taeka Hattori
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Naohiro Yamamoto
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Shizuka Nagase
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Megumi Nukui
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Takeshi Inoue
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Hisashi Kawawaki
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Asako Horino
- Department of Child Brain Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Hiroshi Sakuma
- Department of Child Brain Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
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Watanabe Y, Sano F, Fukao T, Shimizu T, Sawanobori E, Kobayashi A, Fujioka K, Yagasaki H, Inukai T, Kaga Y. Arterial spin labeling perfusion imaging in an infant with anti-N-methyl-D-aspartate receptor encephalitis: A case report. Brain Dev 2022; 44:405-409. [PMID: 35346541 DOI: 10.1016/j.braindev.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/31/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an autoimmune encephalitis characterized by complex neuropsychiatric syndromes and the presence of cerebrospinal fluid (CSF) antibodies against NMDAR. The characteristics of anti-NMDAR encephalitis in children, particularly infants, are unclear due to difficulties in neurologic assessment such as psychiatric symptoms. Additionally, subtle or non-specific findings of conventional magnetic resonance imaging (MRI) make early diagnosis even more difficult. Herein, we present the first case of infant anti-NMDAR encephalitis in which perfusion imaging demonstrated marked abnormalities and the absence of conventional MRI findings. CASE PRESENTATION The patient was an 11-month-old boy who was admitted because of seizure and prolonged fever. He presented with involuntary movements of the mouth and tongue. Brain MRI showed no morphological abnormalities, but three-dimensional arterial spin labeling (ASL) perfusion imaging showed reduced blood flow in the left temporal and frontal regions and the right cerebellum. After that, a positive anti-NMDAR antibody test result was received. Despite treatment with IVIG and methylprednisolone, the involuntary movements and autonomic dysfunction gradually became more prominent. After rituximab administration, the clinical symptoms improved slightly, and follow-up MRI revealed diffuse brain atrophy and improvement in the balance of brain perfusion. CONCLUSIONS To the best of our knowledge, this is the first case report of infantile anti-NMDAR encephalitis in which cerebral blood flow was evaluated using three-dimensional ASL perfusion imaging. Indeed, our case, which showed abnormalities only in ASL perfusion imaging, suggests that CBF assessment could aid in the early diagnosis of anti-NMDAR encephalitis in infants.
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Affiliation(s)
- Yuriko Watanabe
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Fumikazu Sano
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.
| | - Toshimichi Fukao
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tatsuya Shimizu
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Anna Kobayashi
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kaoru Fujioka
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hideaki Yagasaki
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takeshi Inukai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yoshimi Kaga
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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Li R, Jin S, Wang Y, Li JF, Xiao HF, Wang YL, Ma L. Brain Perfusion Alterations on 3D Pseudocontinuous Arterial Spin-Labeling MR Imaging in Patients with Autoimmune Encephalitis: A Case Series and Literature Review. AJNR Am J Neuroradiol 2022; 43:701-706. [PMID: 35393361 PMCID: PMC9089268 DOI: 10.3174/ajnr.a7478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 02/08/2022] [Indexed: 01/26/2023]
Abstract
Autoimmune encephalitis is a heterogeneous group of newly identified disorders that are being diagnosed with increasing frequency. Early recognition and treatment of autoimmune encephalitis are crucial for patients, but diagnosis remains challenging and time-consuming. In this retrospective case series, we describe the findings of conventional MR imaging and 3D pseudocontinuous arterial spin-labeling in patients with autoimmune encephalitis confirmed by antibody testing. All patients with autoimmune encephalitis showed increased CBF in the affected area, even when some of them presented with normal or slightly abnormal findings on conventional MR imaging. Additionally, serial 3D pseudocontinuous arterial spin-labeling showed perfusion reduction in 1 patient after therapy. For patients with highly suspected autoimmune encephalitis, 3D pseudocontinuous arterial spin-labeling may be added to the clinical work-up. Further studies and longitudinal data are needed to corroborate whether and to what extent 3D pseudocontinuous arterial spin-labeling improves the diagnostic work-up in patients with autoimmune encephalitis compared with conventional MR imaging.
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Affiliation(s)
- R. Li
- From the Department of Medical Imaging (R.L., S.J.), Tianjin Huanhu Hospital, Tianjin, China,Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China,Department of Medical Imaging (R.L., S.J.), Affiliated Huanhu Hospital of Nankai University, Tianjin, China
| | - S. Jin
- From the Department of Medical Imaging (R.L., S.J.), Tianjin Huanhu Hospital, Tianjin, China,Department of Medical Imaging (R.L., S.J.), Affiliated Huanhu Hospital of Nankai University, Tianjin, China
| | - Y. Wang
- Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China
| | - J.-F. Li
- Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China
| | - H.-F. Xiao
- Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China
| | - Y.-L. Wang
- Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China
| | - L. Ma
- Department of Radiology (R.L., Y.W., J.-F.L., H.-F.X., Y.-L.W., L.M.), The First Medical Center of PLA General Hospital, Beijing, China
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Seery N, Butzkueven H, O'Brien TJ, Monif M. Contemporary advances in anti-NMDAR antibody (Ab)-mediated encephalitis. Autoimmun Rev 2022; 21:103057. [PMID: 35092831 DOI: 10.1016/j.autrev.2022.103057] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 12/18/2022]
Abstract
The study of antibody (Ab)-mediated encephalitis has advanced dramatically since the discovery of antibodies directed against the N-methyl-D-aspartate receptor (NMDAR) in association with a unique neuro-psychiatric syndrome, over a decade-and-a-half ago. Anti-NMDAR Ab-mediated encephalitis now represents the most well characterised form of autoimmune encephalitis. The disease most commonly manifests in young women, but all ages and both sexes can be affected. Autoantibodies may arise in the context of two well-recognised disease triggers in a proportion of patients, and ultimately facilitate NMDAR displacement from synapses. Various CSF cytokines, chemokines, and other molecules have been explored as candidate biomarkers but are limited in sensitivity and specificity. The clinical spectrum is diverse, with evolution and a combination of neuro-psychiatric abnormalities at disease nadir common. Anti-NMDAR Ab-mediated encephalitis is immunotherapy responsive, and a near-majority ultimately acquire a broadly favourable clinical outcome. The diagnosis, and more particularly, the management of the disease can still hold considerable challenges. Moreover, well-defined biomarkers remain elusive. The present review will therefore delineate pathogenic and clinical advances to date in anti-NMDAR antibody-mediated encephalitis.
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Affiliation(s)
- Nabil Seery
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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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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Miao A, Liu Q, Li Z, Liu W, Wang L, Ge J, Yu C, Wang Y, Huang S, Yu Y, Shi Q, Sun J, Wang X. Altered cerebral blood flow in patients with anti-NMDAR encephalitis. J Neurol 2020; 267:1760-1773. [PMID: 32130498 DOI: 10.1007/s00415-020-09747-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/20/2020] [Accepted: 02/01/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study aimed to identify to resting-state cerebral blood flow (CBF) connectivity alterations in patients with anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. METHODS Three-dimensional pseudo-continuous arterial spin labeling (pcASL) imaging was performed to measure the resting-state CBF in 23 patients with anti-NMDAR encephalitis at the peak stage of the disease and 32 healthy subjects. CBF was normalized to reduce variations among subjects. CBF was compared between the groups, and the correlations between the CBF alterations and clinical parameters were assessed. Differences in CBF connectivity in specific brain regions were also compared between groups. RESULTS Compared with the healthy subjects, the patients with anti-NMDAR encephalitis exhibited increased CBF in the left insula (L_insula), left superior temporal lobe (L_STL), L_hippocampus, L_pallidum, bilateral putamen (Bi_putamen), and Bi_caudate, and decreased CBF in the bilateral precuneus (Bi_Pc) and bilateral occipital lobe (Bi_OL) (P < 0.05, FEW corrected). Compared with healthy subjects, the patients with anti-NMDAR encephalitis exhibited increased negative CBF connectivity between the Bi_Pc, Bi_OL and L_TL, L_insula (P < 0.05, FEW corrected). Anti-NMDAR encephalitis patients with behavioral changes exhibited higher CBF in the L_insula and lower CBF in the R_Pc, Bi_calcarine, Bi_cuneus, and Bi_lingual than patients without behavioral changes and health controls. The ROC curve shows changed CBF in the L_insula, and R_Pc, Bi_calcarine, Bi_cuneus, and Bi_lingual served as a predictor of behavioral changes in patients with anti-NMDAR encephalitis. CONCLUSIONS Our results suggest that patients with anti-NMDAR encephalitis may exhibit both regional CBF abnormalities and deficits in CBF connectivity, which may underlie the clinical symptoms of anti-NMDAR encephalitis.
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Affiliation(s)
- Ailiang Miao
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
- Department of Video-Electroencephalogram, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qianqian Liu
- Department of Pediatrics, Nanjing Jiangning Hospital, Nanjing, 210029, Jiangsu, China
| | - Zonghong Li
- Department of Imaging, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wen Liu
- Department of Imaging, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lingling Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Jianqing Ge
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Chuanyong Yu
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Yingxin Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
- Department of Video-Electroencephalogram, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shuyang Huang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | | | - Qi Shi
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Jintao Sun
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China
| | - Xiaoshan Wang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing Medical University, Guang Zhou Road 264, Nanjing, 210029, Jiangsu, China.
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Kasahara H, Sato M, Nagamine S, Makioka K, Tanaka K, Ikeda Y. Temporal Changes on 123I-Iomazenil and Cerebral Blood Flow Single-photon Emission Computed Tomography in a Patient with Anti-N-methyl-D-aspartate Receptor Encephalitis. Intern Med 2019; 58:1501-1505. [PMID: 30713292 PMCID: PMC6548939 DOI: 10.2169/internalmedicine.0987-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A 45-year-old man was admitted due to tonic seizures, aphasia, disturbance of consciousness, and abnormal behavior. Because cerebral magnetic resonance imaging findings were normal and mild cerebrospinal fluid (CSF) pleocytosis was observed, autoimmune encephalitis was suspected. The presence of anti-N-methyl-D-aspartate (NMDA) receptor antibodies in the CSF was subsequently confirmed. 123I-Iomazenil and cerebral blood flow single photon emission computed tomography (SPECT) revealed an abnormal uptake in the left frontotemporal region. Multimodal immunotherapy was administered, which remarkably improved the level of consciousness. Progressive reversibility of SPECT findings with clinical improvement suggested that the disorder-related functional deficits had been caused by anti-NMDA receptor antibodies.
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Affiliation(s)
- Hiroo Kasahara
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Masayuki Sato
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Shun Nagamine
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Kouki Makioka
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
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10
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Kovac S, Alferink J, Ahmetspahic D, Arolt V, Melzer N. [Update on anti-N-methyl-D-aspartate receptor encephalitis]. DER NERVENARZT 2019; 89:99-112. [PMID: 28932896 DOI: 10.1007/s00115-017-0405-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Autoimmune encephalitis is a group of autoimmune inflammatory disorders affecting both grey and white matter of the central nervous system. Encephalitis with autoantibodies against the N‑methyl-D-aspartate receptor (NMDA-R) is the most frequent autoimmune encephalitis syndrome presenting with a characteristic sequence of psychiatric and neurological symptoms. Treatment necessitates a close interdisciplinary cooperation. This article provides an update on the current knowledge on diagnostic standards, pathogenesis, and treatment strategies for anti-NMDA-R encephalitis from psychiatric and neurological perspectives.
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Affiliation(s)
- S Kovac
- Klinik für Allgemeine Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - J Alferink
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - D Ahmetspahic
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - V Arolt
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - N Melzer
- Klinik für Allgemeine Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
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Brain perfusion SPECT with 99mTc-HMPAO in the diagnosis and follow-up of patients with anti-NMDA receptor encephalitis. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Brain perfusion SPECT with 99mTc-HMPAO in the diagnosis and follow-up of patients with anti-NMDA receptor encephalitis. Neurologia 2018; 33:622-623. [PMID: 27452621 DOI: 10.1016/j.nrl.2016.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/28/2016] [Accepted: 05/30/2016] [Indexed: 11/20/2022] Open
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Constantinides VC, Kasselimis DS, Paraskevas GP, Zacharopoulou M, Andreadou E, Evangelopoulos ME, Kapaki E, Kilidireas C, Stamboulis E, Potagas C. Anti-NMDA receptor encephalitis presenting as isolated aphasia in an adult. Neurocase 2018; 24:188-194. [PMID: 30293488 DOI: 10.1080/13554794.2018.1524915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anti-NMDA receptor (NMDA-r) encephalitis is a relatively rare cause of autoimmune encephalitis with divergent clinical presentations. We report a case of an adult patient with anti-NMDA-r encephalitis presenting with isolated, abrupt-onset aphasia. Her condition remained unaltered over a period of 6 months. The patients' electroencephalogram findings were typical for NMDA-r encephalitis; however, her magnetic resonance imaging and cerebrospinal fluid analysis were normal. She responded well to immunotherapy, and aphasia eventually resolved. The natural course of the present case contradicts the rapidly progressive nature of typical NMDA-r encephalitis. Furthermore, it broadens the clinical spectrum of anti-NMDA-r encephalitis, to incorporate isolated, nonprogressive aphasia.
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Affiliation(s)
- Vasilios C Constantinides
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Dimitrios S Kasselimis
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece.,b Department of Psychiatry , School of Medicine, University of Crete , Heraklion , Greece
| | - George P Paraskevas
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Maria Zacharopoulou
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Elisabeth Andreadou
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | | | - Elisabeth Kapaki
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Costas Kilidireas
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Eleftherios Stamboulis
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
| | - Constantin Potagas
- a 1st Department of Neurology , National and Kapodistrian University of Athens, Eginition Hospital , Athens , Greece
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Nicolle DCM, Moses JL. A Systematic Review of the Neuropsychological Sequelae of People Diagnosed with Anti N-Methyl-D-Aspartate Receptor Encephalitis in the Acute and Chronic Phases. Arch Clin Neuropsychol 2018; 33:964-983. [DOI: 10.1093/arclin/acy005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/16/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Della C M Nicolle
- Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
| | - Jennifer L Moses
- Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
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Matsumoto H, Hashida H, Takahashi Y. Dystonic Seizures and Intense Hyperperfusion of the Basal Ganglia in a Patient with Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Case Rep Neurol 2017; 9:272-276. [PMID: 29515425 PMCID: PMC5836200 DOI: 10.1159/000484200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/13/2017] [Indexed: 11/20/2022] Open
Abstract
This report describes a rare case presenting with dystonic seizures due to anti-N-methyl-D-aspartate (NMDA) receptor encephalitis. The patient was an 18-year-old woman with repeated right-dominant dystonic seizures even under sedation. Single-photon emission computed tomography (SPECT) showed intense hyperperfusion of the caudate nuclei, putamen, globus pallidus, thalamus, and insula on the left side, suggesting encephalitis. Antibodies against NMDA receptors were detected in the sera and cerebrospinal fluids. Immune-mediated treatments were administered. Three months later, the dystonic seizures disappeared. We diagnosed her with anti-NMDA receptor encephalitis. SPECT suggested that the main region of encephalitis was the basal ganglia. Therefore, we propose that the patient's dystonic seizures may originate from the insula and be generated by intense hyperactivity of the basal ganglia.
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Affiliation(s)
- Hideyuki Matsumoto
- Department of Neurology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hideji Hashida
- Department of Neurology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Yukitoshi Takahashi
- Department of Pediatrics, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
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Sachs JR, Zapadka ME, Popli GS, Burdette JH. Arterial spin labeling perfusion imaging demonstrates cerebral hyperperfusion in anti-NMDAR encephalitis. Radiol Case Rep 2017; 12:833-837. [PMID: 29484082 PMCID: PMC5823289 DOI: 10.1016/j.radcr.2017.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/09/2017] [Indexed: 01/17/2023] Open
Abstract
Anti-N-methyl-d-aspartate receptor encephalitis is an increasingly recognized autoimmune disorder that results in substantial morbidity, prolonged hospital stays, and even death. The diagnosis is often delayed or unrecognized entirely as a result of absent or only subtle initial magnetic resonance imaging findings and a nonspecific clinical syndrome. The discovery of early imaging findings in this disease may help clinicians to more aggressively treat this autoimmune encephalitis and to potentially lessen morbidity and mortality. We report a novel case of anti-N-methyl-d-aspartate receptor encephalitis characterized by early evidence of increased cerebral perfusion on arterial spin labeling perfusion imaging, a finding that preceded laboratory diagnosis and conventional magnetic resonance imaging abnormalities. Further investigation is needed to firmly establish the pathologic basis of this finding.
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Affiliation(s)
- Jeffrey R Sachs
- Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157
| | - Michael E Zapadka
- Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157
| | - Gautam S Popli
- Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157
| | - Jonathan H Burdette
- Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157
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Vasenina EE, Levin OS, Gankina OA, Chimagomedova AS, Levikov DI. Autoimmune anti-NMDA-R encephalitis. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:110-116. [DOI: 10.17116/jnevro201711721110-116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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18
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[Subacute anti-N-methyl-D-aspartate receptor encephalitis. A serie of 13 paediatric cases]. ACTA ACUST UNITED AC 2016; 87:487-493. [PMID: 27476614 DOI: 10.1016/j.rchipe.2016.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [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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Fischer CE, Golas AC, Schweizer TA, Munoz DG, Ismail Z, Qian W, Tang-Wai DF, Rotstein DL, Day GS. Anti N-methyl-D-aspartate receptor encephalitis: a game-changer? Expert Rev Neurother 2016; 16:849-59. [PMID: 27123777 DOI: 10.1080/14737175.2016.1184088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an inflammatory disorder of the brain that has garnered significant interest within the medical and lay communities. There is a need for formal guidelines to assist physicians in identifying patients who should undergo testing for NMDAR encephalitis, recognizing the high potential for this potentially treatable disease to mimic more common disorders, and consequently remain undiagnosed. AREAS COVERED This review highlights the impact of the discovery of NMDAR encephalitis on the fields of neurology and psychiatry, and discusses the steps that are necessary to improve recognition and treatment of NMDAR encephalitis. Expert commentary: While much progress has been made in our understanding of NMDAR encephalitis, much work remains to be done to delineate the underlying disease mechanisms and their relevance to brain function.
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Affiliation(s)
- Corinne E Fischer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,c Faculty of Medicine, Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Angela C Golas
- d Department of Psychiatry , University of Toronto, Geriatric Psychiatry Subspecialty , Toronto , ON , Canada
| | - Tom A Schweizer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,e Institute of Biomaterials and Biomedical Engineering , University of Toronto , Toronto , ON , Canada.,f Division of Neurosurgery, Department of Surgery, Faculty of Medicine , University of Toronto , Toronto , ON , Canada.,g Division of Neurosurgery , St. Michael's Hospital , Toronto , ON , Canada
| | - David G Munoz
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,h Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , ON , Canada.,i Division of Pathology, Department of Laboratory Medicine and Pathobiology , St. Michael's Hospital , Toronto , ON , Canada
| | - Zahinoor Ismail
- j Hotchkiss Brain Institute , University of Calgary , Calgary , AB , Canada
| | - Winnie Qian
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada
| | - David F Tang-Wai
- k Department of Medicine (Neurology and Geriatric Medicine) , University of Toronto , Toronto , ON , Canada.,l UHN Memory Clinic , Toronto Western Hospital , Toronto , ON , Canada
| | - Dalia L Rotstein
- m Department of Medicine (Neurology) , University of Toronto, St. Michael's Hospital , Toronto , ON , Canada
| | - Gregory S Day
- n Knight Alzheimer Disease Research Center, Department of Neurology , Washington University in St. Louis , St. Louis , MO , Canada
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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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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: 1569] [Impact Index Per Article: 120.7] [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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