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Santoro JD, Demakakos P, He S, Kumar S, Murton M, Tennigkeit F, Hemingway C. A systematic review of the epidemiology of pediatric autoimmune encephalitis: disease burden and clinical decision-making. Front Neurol 2024; 15:1408606. [PMID: 39040538 PMCID: PMC11262030 DOI: 10.3389/fneur.2024.1408606] [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: 03/28/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024] Open
Abstract
Background Autoimmune encephalitis (AIE) comprises a group of rare, immune system-mediated conditions. Clinical manifestations among children are not well-characterized, and there are challenges in testing and diagnosis. This can result in treatment delays, which has been found to correlate with poorer long-term outcomes. This challenge is exacerbated by the scarcity of epidemiological reporting of AIE. The objective of this systematic literature review (SLR) was to identify studies reporting epidemiological data on AIE in children. Methods MEDLINE, Embase, the Cochrane Library, and the University of York Centre for Reviews and Dissemination (CRD) were searched in May 2023 for studies reporting on the epidemiology of AIE in children. These were supplemented with additional searches of conference proceedings, gray literature, and the reference lists of identified SLRs. Quality of studies was assessed using a modified version of the Joanna Briggs Institute (JBI) Checklist for Prevalence Studies. Results Forty-three publications reporting on 41 unique studies were included. Nine studies reported incidence estimates of different subtypes of AIE, with only one reporting the incidence of overall AIE in children ≤ 18 years, estimated at 1.54 per million children per year in the Netherlands. Three studies reported the incidence of pediatric N-methyl-D-aspartate receptor (NMDAR)-AIE [in United Kingdom (UK), Hong Kong, and Denmark]. The other studies reported incidence data for selected populations. Conclusion This SLR highlights a paucity of epidemiology data for AIE in children, which is likely reflective of difficulties in testing and diagnosis. There is a clear need for further research and awareness of these challenges in clinical practice to avoid treatment delays and improve patient outcomes. A deeper understanding of the epidemiology of AIE will help determine the worldwide burden of disease and inform research, health policies and clinical decision-making.
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Affiliation(s)
- Jonathan D. Santoro
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | | | - Shiying He
- Costello Medical Singapore Ltd., Singapore, Singapore
| | - Swati Kumar
- Costello Medical Consulting Ltd., Cambridge, United Kingdom
| | - Molly Murton
- Costello Medical Consulting Ltd., Cambridge, United Kingdom
| | | | - Cheryl Hemingway
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
- UCL Queen Square Institute of Neurology, London, United Kingdom
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Lee KW, Khan AHKY, Ching SM, Kumar SJ, Raj CLVP, Chia PK, Basri H, Sulaiman WAW, Mat LNI, Veettil SK, Hoo FK, Loh WC. Prevalence and Factor Associated with Anti-N-Methyl-D-Aspartate Receptor Encephalitis Among Patients with Medical Conditions: A Systematic Review and Meta-Analysis. Neurol India 2024; 72:476-486. [PMID: 39041960 DOI: 10.4103/neuroindia.ni_981_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 04/27/2022] [Indexed: 07/24/2024]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe autoimmune encephalitis due to immune production of anti-NMDAR antibodies against the NR1 subunit of the NMDA receptor which is present throughout the central nervous system. This condition had been reported to be prevalent in patients with certain medical conditions; however so far, there have been limited systematic reviews and meta-analyses on the prevalence and factors associated. OBJECTIVE This study was to determine the prevalence and factors associated with anti-NMDAR encephalitis among affected patients. MATERIAL AND METHODS The protocol of this study has been registered (2019: CRD42019142002) with the International Prospective Register of Systematic Reviews (PROSPERO). The primary outcome was the incidence or prevalence of anti-NMDAR encephalitis and secondary outcomes were factors associated with anti-NMDAR encephalitis. RESULTS There were 11 studies and a total of 873 million patients taken from high-risk populations across 11 countries that were included in the primary analysis. The overall pooled prevalence of anti-NMDAR encephalitis among patients with medical conditions was 7.0% (95% CI = 4.4, 9.6). Those with first episode of psychosis or schizophrenia were at a higher risk of developing anti-NMDAR encephalitis with an odds ratio of 5.976 (95% CI = 1.122, 31.825). CONCLUSION We found that almost one-tenth of patients with medical conditions had anti-NMDAR encephalitis; particularly those with first episode of psychosis or schizophrenia were among the high-risk medical conditions.
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Affiliation(s)
- Kai Wei Lee
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Abdul Hanif Khan Yusof Khan
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Siew Mooi Ching
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Sathish Jaya Kumar
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Charlene Lily Vincent Paul Raj
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Peck Kee Chia
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Hamidon Basri
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Wan Aliaa Wan Sulaiman
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Liyana Najwa Inche Mat
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Sajesh K Veettil
- School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia, Kuala Lumpur, Malaysia
| | - Fan Kee Hoo
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Wei Chao Loh
- Department of Neurology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Hulliger LF, Tscherter A, Kuehni CE, Bigi S. Protocol on establishing a national disease registry-Swiss Pediatric Inflammatory Brain Disease Registry. PLoS One 2024; 19:e0290908. [PMID: 38626083 PMCID: PMC11020937 DOI: 10.1371/journal.pone.0290908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/28/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Pediatric-onset inflammatory brain diseases are a group of potentially life-threatening central nervous system disorders. Overall, pediatric-onset inflammatory brain diseases are rare and therefore difficult to study. Patient registries are well suited to study the natural history of (rare) diseases and have markedly advanced the knowledge on pediatric-onset inflammatory brain diseases in other countries. Following their example, we established a national pediatric-onset inflammatory brain disease registry in Switzerland (Swiss-Ped-IBrainD). AIMS The Registry aims to describe epidemiology, demographics, diagnostics, management, and treatment, since these areas remain understudied in Switzerland. Additionally, we want to promote research by fostering the knowledge exchange between study centers and setting up studies such as national quality of life surveys. We further aim to facilitate the access to national and international studies for patients with a pediatric-onset inflammatory brain disease living and/or treated in Switzerland. METHODS The Swiss-Ped-IBrainD is a multicentric, population-based, observational cohort study (IRB number: 2019-00377) collaborating with 11 neuropediatric centers in Switzerland. Patient screening, information and recruitment is mainly conducted by the local principal investigators. The data collection is organized centrally by the Executive Office of the registry. The collected data is purely observational. Medical records are the primary data source. All patients who have been diagnosed with a pediatric-onset inflammatory brain disease since 2005 are eligible. We aim to include all pediatric-onset inflammatory brain disease patients living and/or treated in Switzerland who meet the inclusion criteria. Considering existing literature and our single-center experience we anticipate 300-400 eligible patients. STATUS Currently, all 11 neuropediatric centers have been initiated and are recruiting. As of the first of May 2023, we have identified 275 eligible participants and obtained informed consent from 101 patients and/or families. None of the informed patients and/or families have refused participation.
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Affiliation(s)
| | - Anne Tscherter
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Sandra Bigi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Neuropediatrics, Lucerne Cantonal Hospital, Children’s Hospital of Central Switzerland, Luzern, Switzerland
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Alentorn A, Berzero G, Alexopoulos H, Tzartos J, Reyes Botero G, Morales Martínez A, Muñiz-Castrillo S, Vogrig A, Joubert B, García Jiménez FA, Cabrera D, Tobon JV, Delgado C, Sandoval P, Troncoso M, Galleguillos L, Giry M, Benazra M, Hernández Verdin I, Dade M, Picard G, Rogemond V, Weiss N, Dalakas MC, Boëlle PY, Delattre JY, Honnorat J, Psimaras D. Spatial and Ecological Factors Modulate the Incidence of Anti-NMDAR Encephalitis-A Systematic Review. Biomedicines 2023; 11:1525. [PMID: 37371620 PMCID: PMC10295747 DOI: 10.3390/biomedicines11061525] [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: 08/19/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 06/29/2023] Open
Abstract
Anti-NMDAR encephalitis has been associated with multiple antigenic triggers (i.e., ovarian teratomas, prodromal viral infections) but whether geographic, climatic, and environmental factors might influence disease risk has not been explored yet. We performed a systematic review and a meta-analysis of all published papers reporting the incidence of anti-NMDAR encephalitis in a definite country or region. We performed several multivariate spatial autocorrelation analyses to analyze the spatial variations in the incidence of anti-NMDA encephalitis depending on its geographical localization and temperature. Finally, we performed seasonal analyses in two original datasets from France and Greece and assessed the impact of temperature using an exposure-lag-response model in the French dataset. The reported incidence of anti-NMDAR encephalitis varied considerably among studies and countries, being higher in Oceania and South America (0.2 and 0.16 per 100,000 persons-year, respectively) compared to Europe and North America (0.06 per 100,000 persons-year) (p < 0.01). Different regression models confirmed a strong negative correlation with latitude (Pearson's R = -0.88, p < 0.00001), with higher incidence in southern hemisphere countries far from the equator. Seasonal analyses showed a peak of cases during warm months. Exposure-lag-response models confirmed a positive correlation between extreme hot temperatures and the incidence of anti-NMDAR encephalitis in France (p = 0.03). Temperature analyses showed a significant association with higher mean temperatures and positive correlation with higher ultraviolet exposure worldwide. This study provides the first evidence that geographic and climatic factors including latitude, mean annual temperature, and ultraviolet exposure, might modify disease risk.
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Affiliation(s)
- Agustí Alentorn
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Giulia Berzero
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - John Tzartos
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 72-74, Vas. Sofias Ave, 11528 Athens, Greece
| | - Germán Reyes Botero
- Department of Oncology, Neuro-Oncology Section, Hospital Pablo Tobón Uribe, Medellín 050010, Colombia
| | - Andrea Morales Martínez
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Departments of Neurology and Neurosurgery, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Alberto Vogrig
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Francisco A. García Jiménez
- Department of Neurology, Faculty of Medicine, University of Antioquia, Carrera 51d N° 62-29, Medellín 050010, Colombia
- Department of Neurology, Hospital Universitario San Vicente Fundación, Calle 64N° 51d-154, Medellín 050010, Colombia
| | - Dagoberto Cabrera
- Deparment of Neuropediatry, Hospital Universitario San Vicente Fundación, Calle 64N° 51d-154, Medellín 050010, Colombia
| | - José Vladimir Tobon
- Instituto Neurologico de Colombia, University of Antioquia, Medellin 050010, Colombia
| | - Carolina Delgado
- Departments of Neurology and Neurosurgery, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Patricio Sandoval
- Department of Neurology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
| | - Mónica Troncoso
- Department of Pediatric Neurology, Hospital Clínico San Borja Arriarán, Facultad de Medicina, Campus Centro, Universidad de Chile, Santiago 7800003, Chile
| | | | - Marine Giry
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Marion Benazra
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Isaias Hernández Verdin
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Maëlle Dade
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Géraldine Picard
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Véronique Rogemond
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Nicolas Weiss
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
- Department of Neurology, Neuro ICU, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
| | - Marinos C. Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Pierre-Yves Boëlle
- INSERM, Sorbonne Université, Institut Pierre Louis d’Épidémiologie et de Santé Publique, 75012 Paris, France
| | - Jean-Yves Delattre
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, 69677 Bron, France
- Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, 69372 Lyon, France
| | - Dimitri Psimaras
- Department of Neurology 2 Mazarin, Hôpitaux Universitaires La Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, APHP, 75013 Paris, France
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Université Pierre-et-Marie-Curie, Sorbonnes Universités, 75005 Paris, France
- Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes, Groupe Hospitalier Pitié-Salpêtrière, 75013 Paris, France
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Neuropsychological functioning in children and adolescents with anti-NMDA receptor encephalitis (anti-NMDARE). J Neurol 2023; 270:402-412. [PMID: 36112199 DOI: 10.1007/s00415-022-11372-9] [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: 05/24/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023]
Abstract
The objective of this study was to describe neuropsychological functioning and associated medical features in pediatric patients with anti-NMDA receptor encephalitis (anti-NMDARE). Retrospective data were collected from electronic medical records and neuropsychological reports of 15 children and adolescents with cerebral spinal fluid antibody-confirmed anti-NMDARE who were 7-21 years old at the time of the neuropsychological evaluation. The median time between treatment initiation for anti-NMDARE and neuropsychological testing was 228 days (IQR 431, range 41-927). Consistent with the limited literature, this pediatric sample with anti-NMDARE generally had average IQs, but had scores falling in the low average range on tests of verbal and visual memory as well as aspects of executive functioning (set shifting and phonemic verbal fluency). Other relative weaknesses were observed in visuo-constructional ability and reading comprehension. Future prospective studies are needed to replicate these data and explore disease and treatment variables that reduce or exacerbate the risk for neuropsychological sequelae, while longitudinal analyses are required to better characterize academic, vocational, and social outcomes.
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Nguyen L, Yang JH, Goyal S, Irani N, Graves JS. A systematic review and quantitative synthesis of the long-term psychiatric sequelae of pediatric autoimmune encephalitis. J Affect Disord 2022; 308:449-457. [PMID: 35429531 DOI: 10.1016/j.jad.2022.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term neuropsychiatric sequelae of autoimmune encephalitis (AE) remain understudied, particularly in pediatric-onset AE. We aimed to synthesize the published data on ongoing psychiatric symptoms in pediatric-onset AE. METHODS The Pubmed, PyscINFO, Web of Science databases were searched from their inception years to August 23, 2021, and 29 studies were identified and analyzed. We also performed a quantitative synthesis of available patient data from the 29 studies combined with a cohort of anti-NMDA receptor (NMDAR) AE from our institution to examine the associations between acute treatment course and long-term psychiatric outcome. RESULTS At long-term follow up, 52.4% of the cases with pediatric-onset AE had any persistent symptom and 36.0% had at least one psychiatric symptom. Pooled data found that 36.3% of pediatric-onset anti-NMDAR AE had ongoing psychiatric symptoms. Using a univariate logistic regression analysis, we found that abnormal initial EEG, use of certain immunotherapies, and persistent cognitive impairments were associated with ongoing psychiatric symptoms. LIMITATIONS Limitations of the existing literature included a significant paucity of outcomes measured using consistent, objective methods. Limitations of the systematic review included the wide variability among the studies reviewed, which rendered a meta-analysis impossible and beyond the scope of the paper. CONCLUSION Chronic psychiatric and behavioral problems remain present in one-third of children months to years after onset of AE. Larger scaled prospective observational studies with a consistent standardized battery of testing are needed to examine impact of specific clinical features and immunotherapies on long-term mental health outcomes.
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Affiliation(s)
- Linda Nguyen
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Jennifer H Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Sajan Goyal
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Najin Irani
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, USA; Division of Neurology, Rady Children's Hospital San Diego, San Diego, CA, USA
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Bastiaansen AEM, de Bruijn MAAM, Schuller SL, Martinez-Hernandez E, Brenner J, Paunovic M, Crijnen YS, Mulder MJHL, Schreurs MWJ, de Graaff E, Smitt PAE, Neuteboom RF, de Vries JM, Titulaer MJ. Anti-NMDAR Encephalitis in the Netherlands, Focusing on Late-Onset Patients and Antibody Test Accuracy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/2/e1127. [PMID: 34937737 PMCID: PMC8696553 DOI: 10.1212/nxi.0000000000001127] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/10/2021] [Indexed: 01/21/2023]
Abstract
Background and Objectives To describe the clinical features of anti-NMDAR encephalitis, emphasizing on late-onset patients and antibody test characteristics in serum and CSF. Methods Nationwide observational Dutch cohort study, in patients diagnosed with anti-NMDAR encephalitis between 2007 and 2019. Results One hundred twenty-six patients with anti-NMDAR encephalitis were included with a median age of 24 years (range 1–86 years). The mean annual incidence was 1.00/million (95% CI 0.62–1.59). Patients ≥45 years of age at onset (19%) had fewer seizures (46% vs 71%, p = 0.021), fewer symptoms during disease course (3 vs 6 symptoms, p = 0.020), and more often undetectable serum antibodies compared with younger patients (p = 0.031). In the late-onset group, outcome was worse, and all tumors were carcinomas (both p < 0.0001). CSF was more accurate than serum to detect anti-NMDAR encephalitis (sensitivity 99% vs 68%, p < 0.0001). Using cell-based assay (CBA), CSF provided an unconfirmed positive test result in 11/2,600 patients (0.4%); 6/11 had a neuroinflammatory disease (other than anti-NMDAR encephalitis). Patients with anti-NMDAR encephalitis, who tested positive in CSF only, had lower CSF antibody titers (p = 0.003), but appeared to have an equally severe disease course. Discussion Anti-NMDAR encephalitis occurs at all ages and is less rare in the elderly patients than initially anticipated. In older patients, the clinical phenotype is less outspoken, has different tumor association, and a less favorable recovery. Detection of antibodies in CSF is the gold standard, and although the CBA has very good validity, it is not perfect. The clinical phenotype should be leading, and confirmation in a research laboratory is recommended, when in doubt.
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Affiliation(s)
- Anna E M Bastiaansen
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Marienke A A M de Bruijn
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Sabine L Schuller
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Eugenia Martinez-Hernandez
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Juliëtte Brenner
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Manuela Paunovic
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Yvette S Crijnen
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Maxim J H L Mulder
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Marco W J Schreurs
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Esther de Graaff
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Peter A E Smitt
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Rinze F Neuteboom
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Juna M de Vries
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Maarten J Titulaer
- From the Department of Neurology (A.E.M.B., M.A.A.M.d.B., J.B., M.P., Y.S.C., M.J.H.L.M., P.A.E.S., R.F.N., J.M.d.V., M.J.T.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (M.A.A.M.d.B.), Elisabeth Tweesteden Medical Center, the Netherlands; Bachlelor Student Psychobiology (S.L.S.), University of Amsterdam, the Netherlands; Neuroimmunology Program and Department of Neurology (E.M.-H.), Hospital Clínic, University of Barcelona, Spain; Department of Immunology (M.W.J.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Biology (E.d.G.), Faculty of Science, Utrecht University, Utrecht, the Netherlands.
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8
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Zhang J, Sun J, Zheng P, Feng S, Yi X, Ren H, Chen Q. Clinical Characteristics and Follow-Up of Seizures in Children With Anti-NMDAR Encephalitis. Front Neurol 2022; 12:801289. [PMID: 35069429 PMCID: PMC8766335 DOI: 10.3389/fneur.2021.801289] [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: 10/25/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To analyze the seizure characteristics of children with anti-NMDAR encephalitis. Methods: This was a retrospective analysis of 50 children with anti-NMDAR encephalitis between July 1, 2013, and July 1, 2019. Results: Fifty children with anti-NMDAR encephalitis were included in this study, of which 34 (68.0%) had seizures. During the follow-up, three patients with anti-NMDAR encephalitis secondary to herpes simplex virus encephalitis had persistent seizures. The average duration of seizures in the remaining patients was 14.6 days (range 1–47 days). Compared to patients without seizures, those with seizures were more likely to experience consciousness disturbances (p = 0.008) and epileptic form discharge on electroencephalograms (p = 0.002). The Glasgow coma scale scores (p = 0.014), and Rankin scale scores (p = 0.019) were also different. The cranial MRI findings of children were reviewed, and clinical characteristics were compared between children without cranial lesions and those with lesions in the limbic system and neocortex. Compared to children in the non-lesion group, children with lesions in the limbic system and neocortex had a higher incidence of status epilepticus. Further, children in the limbic system and neocortical lesions groups were more likely to be taking anti-seizure medications (ASMs) and receive second-line drugs. Conclusion: Long-term oral ASMs are not recommended for most children with anti-NMDAR encephalitis. Children with involvement of the limbic system and neocortex are prone to status epilepticus, and sequelae of epilepsy may remain when the neocortex is involved.
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Affiliation(s)
- Jianzhao Zhang
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Jing Sun
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Ping Zheng
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Shuo Feng
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Xiaoli Yi
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Qian Chen
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
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9
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Age-dependent characteristics and prognostic factors of pediatric anti-N-methyl-d-aspartate receptor encephalitis in a Chinese single-center study. Eur J Paediatr Neurol 2021; 34:67-73. [PMID: 34399369 DOI: 10.1016/j.ejpn.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the clinical features and prognosis of pediatric anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis from a single center in northern China. METHODS The clinical and laboratory characteristics of hospitalized patients with anti-NMDAR encephalitis, stratified by age, were retrospectively studied. Risk factors including relapse and long-term (follow-up ≥1 year) outcomes were analyzed. RESULTS A total of 273 patients were included between November 2011 and December 2019, and the average age of onset was 7.5 ± 4.0 years (0.5-15.8 years). Of them, 159(58.2%) were female, and the proportion of females increased with age. Seizures were the most common initial symptom. Movement disorders(86.1%) and psychiatric(82.4%) symptoms were most frequent in the acute phase. In the acute stage, the incidence of movement disorders decreased with age (χ2 = 10.676, p = 0.011), while the proportion of psychiatric symptoms increased with age (χ2 = 21.85, p < 0.001) The recurrence rate was 9.6% (24/250). Demyelination was an independent risk factor for relapse (p = 0.006, OR = 5.877, 95% CI: 1.658-20.835). Among the 210 patients who were followed up for more than one year, 28 patients had a poor prognosis (mRS ≥3). Onset age (p = 0.038,OR = 0.844, 95% CI: 0.720-0.991), precursor of viral encephalitis (p = 0.007,OR = 9.876, 95% CI: 1.878-51.940), and ICU admission (p = 0.023,OR = 5.924, 95% CI: 1.280-27.064) significantly affected the prognosis. The mortality rate was 2.9%. CONCLUSIONS The characteristics of anti-NMDAR encephalitis in children are age-dependent. Early-onset, the precursor of viral encephalitis, and ICU admission may indicate poor prognosis. Demyelination may be a risk factor for recurrence.
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10
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Wilkinson-Smith A, Blackwell LS, Howarth RA. Neuropsychological outcomes in children and adolescents following anti-NMDA receptor encephalitis. Child Neuropsychol 2021; 28:212-223. [PMID: 34435553 DOI: 10.1080/09297049.2021.1965110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anti-N-methyl-d-aspartate receptor encephalitis (ANMDARE) is a neurologic disorder that is becoming more recognized in children and adolescents. Early studies suggested that patients typically recover well, but more recent data suggests that children may experience persistent cognitive deficits, especially in verbal memory and executive functioning. The aims of this study are to evaluate areas of impairment and to characterize neuropsychological outcomes in pediatric patients with ANMDARE. This was a multi-centered retrospective chart review. We identified 23 pediatric patients who were, on average, 18.5 months from diagnosis. Patients underwent comprehensive neuropsychological assessment, including measures of intellectual functioning, memory, reading, verbal fluency, visuomotor skills, attention, and working memory. Caregiver ratings and information regarding resource utilization were also collected (e.g., formal school services, outpatient rehabilitation, psychological support). Neuropsychological impairment index (NPI) scores were calculated for each patient. Neuropsychological outcomes highlighted variability across individuals. Memory and fine motor dexterity were particularly impacted. Almost 90% of caregivers reported more concerns than average on at least one measure of emotional-behavioral, adaptive, or executive functioning. More than two-thirds of the sample were considered impaired based on NPI scores on performance measures. More than three quarters of the sample received outpatient intervention, most often consisting of school-based services. Our findings provide additional quantitative evidence that pediatric patients recovering from ANMDARE demonstrate ongoing cognitive concerns. While most patients experience remarkable recoveries following appropriate diagnosis and treatment, ongoing monitoring and support is recommended over time for these patients.
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Affiliation(s)
- Alison Wilkinson-Smith
- Department of Psychological Services, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laura S Blackwell
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
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11
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Li Q, Fu N, Han Y, Qin J. Pediatric Autoimmune Encephalitis and Its Relationship With Infection. Pediatr Neurol 2021; 120:27-32. [PMID: 33964702 DOI: 10.1016/j.pediatrneurol.2021.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/31/2022]
Abstract
Autoimmune encephalitis (AE) is an increasingly recognized inflammatory disorder of the central nervous system and is most often characterized by antibodies against intracellular and neuronal surface antigens. AE is a devastating disease that may result in developmental delay or regression in children. However, the pathogenesis of AE is not clear, and immune system disorders after infection likely play an important role in AE. Many studies have reported that patients with herpes simplex virus encephalitis develop anti-N-methyl-d-aspartate receptor encephalitis after antiviral treatment. It is critical to recognize pediatric AE early and to distinguish it from infectious forms because AE is treatable and responsive to immunotherapies. In this review, we discuss the clinical features of pediatric AE and focus on the relationship between AE and postinfection status. In addition, we review the probable mechanisms underlying infection-triggered AE, which include molecular mimicry, bystander activation, epitope spreading, immune system disorder, and genetic susceptibility.
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Affiliation(s)
- Qinrui Li
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Na Fu
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Ying Han
- Department of Pediatrics, Peking University First Hospital, Beijing, P.R. China.
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China.
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12
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Reyes NGD, Espiritu AI, Agabao JF, Abejero JEE, Salonga-Quimpo RAM, Cabral-Lim LI, Jamora RDG, Pascual V JLR, Fernandez MLL, Gosiengfiao KTP. Autoimmune encephalitis in a tertiary hospital in the Philippines. J Clin Neurosci 2021; 90:191-198. [PMID: 34275548 DOI: 10.1016/j.jocn.2021.05.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/08/2020] [Accepted: 05/23/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is an emerging disorder in adults and children. Due to its potentially reversible nature, prompt recognition and intervention are of utmost importance. OBJECTIVE To describe the clinical and paraclinical features, as well as treatment outcomes of patients with AE admitted in a Philippine tertiary hospital. METHODS Retrospective case series of patients with definite AE. RESULTS Eighteen (18) patients were included (12 adults, 6 children), majority of whom had anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. The median age of onset was 32 (IQR: 10.8) years old and 13 (IQR: 4.8) years old in the adult and pediatric population, respectively. In both age groups, most presented with psychiatric symptoms and normal imaging findings. Cerebrospinal fluid (CSF) pleocytosis was detected in 8/12 (66.7%) adults and 2/6 (33.3%) children, while CSF protein elevation was only seen in 6/12 (50%) adults. Most patients presented with seizures, and the most frequent electroencephalography (EEG) abnormality detected was slow activity (70.5%). A high proportion of patients received high dose steroids, alone (35.3%) or in combination with intravenous immunoglobulin (IVIG, 52.9%). Overall, 66.7% had improved outcomes, mostly seen in the pediatric population. CONCLUSION This study highlighted the broad clinical phenotype, as well as the similarities and differences of AE manifestations in adults and children. It demonstrated the limited but supportive role of laboratory investigations in the diagnosis of AE. It also underscored the importance of early intervention in AE and highlighted factors influencing treatment practices and discharge outcomes in the local setting.
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Affiliation(s)
- Nikolai Gil D Reyes
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Adrian I Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines.
| | - Jerson F Agabao
- Division of Pediatric Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Joshua Emmanuel E Abejero
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Rhea Angela M Salonga-Quimpo
- Division of Pediatric Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Leonor I Cabral-Lim
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Roland Dominic G Jamora
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Jose Leonard R Pascual V
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Marc Laurence L Fernandez
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Katerina Tanya P Gosiengfiao
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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13
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Wong CK, Hor JY, Loo YP, Heng HS, Lee S, Perianen PP, Ong SAM, Majawit EM, Chang AYP, Chia YK, Leite MI. High incidence of NMDAR encephalitis among Austronesians: A population-based study in Sabah, Malaysia. J Neuroimmunol 2021; 356:577584. [PMID: 33933821 DOI: 10.1016/j.jneuroim.2021.577584] [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: 01/06/2021] [Revised: 04/05/2021] [Accepted: 04/22/2021] [Indexed: 11/19/2022]
Abstract
NMDAR encephalitis may be more common among non-Caucasians. A population-based study was conducted to estimate its incidence in Sabah, Malaysia, where the population consists predominantly of Austronesians (84%), and with a Chinese minority. Registries of NMDAR encephalitis at neurology referral centers were reviewed for case ascertainment. The annual incidence was 2.29/million (Austronesians: 2.56/million, Chinese: 1.31/million). Among pediatric population, the incidence was: Austronesians: 3.63/million, Chinese: 2.59/million. Our study demonstrated a higher incidence of NMDAR encephalitis among Austronesians than the predominantly Caucasian populations in Europe (0.5-0.9/million; pediatric: 0.7-1.5/million). Racial and genetic factors may contribute to risks of developing NMDAR encephalitis.
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Affiliation(s)
- Chee Keong Wong
- Neurology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | - Jyh Yung Hor
- Department of Neurology, Penang General Hospital, Penang, Malaysia.
| | - Yin Pin Loo
- Department of Neurology, Penang General Hospital, Penang, Malaysia
| | - Hock Sin Heng
- Paediatric Neurology Unit, Sabah Women & Children's Hospital, Kota Kinabalu, Malaysia
| | - Shirley Lee
- Neurology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | | | | | - Elyssa Milus Majawit
- Paediatric Neurology Unit, Sabah Women & Children's Hospital, Kota Kinabalu, Malaysia
| | | | - Yuen Kang Chia
- Neurology Unit, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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14
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Hutchinson ML, Yeshokumar AK, Armangue T. Antibody-Mediated Encephalitis in Children: Focus on Diagnostic Clues and Acute Symptom Management. Semin Pediatr Neurol 2021; 37:100873. [PMID: 33892846 DOI: 10.1016/j.spen.2021.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 01/18/2023]
Abstract
Antibody-mediated encephalitis is a treatable cause of encephalitis that manifests over days to weeks as changes in behavior and cognition, seizures, movement disorders, and autonomic dysfunction. Patients with autoimmune encephalitis develop a variety of symptoms. As such, they require a multidisciplinary approach to care. In this review we summarize the clinical presentation and practical diagnostic approach to pediatric autoimmune encephalitis, review treatments of the autoimmune process, and discuss the management of the acute symptoms encountered in children.
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Affiliation(s)
| | - Anusha K Yeshokumar
- Departments of Neurology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain
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15
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Bozzola E, Spina G, Valeriani M, Papetti L, Ursitti F, Agostiniani R, Mascolo C, Ruggiero M, Di Camillo C, Quondamcarlo A, Matera L, Vecchio D, Memo L, Villani A. Management of pediatric post-infectious neurological syndromes. Ital J Pediatr 2021; 47:17. [PMID: 33494818 PMCID: PMC7836589 DOI: 10.1186/s13052-021-00968-y] [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: 07/25/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-Infectious Neurological Syndromes (PINS) are heterogeneous neurological disorders with post or para-infectious onset. PINS diagnosis is complex, mainly related to the absence of any recognized guidelines and a univocal definition. AIM OF THE STUDY To elaborate a diagnostic guide for PINS. MATERIALS AND METHODS We retrospectively analysed patients younger than 14 years old admitted to Bambino Gesù Children's Hospital in Rome for PINS from December 2005 to March 2018. Scientific literature using PubMed as research platform was analysed: the key words "Post-Infectious Neurological Syndromes" were used. RESULTS A polysymptomatic presentation occurred in a percentage of 88% of the children. Motor signs and visual disturbances the most observed symptoms/signs were the most detached, followed by fever, speech disturbances, sleepiness, headache and bradipsychism. Blood investigations are compatible with inflammation, as a prodromal illnesses was documented in most cases. Normal cerebral spinal fluid (CSF) characteristics has been found in the majority of the study population. Magnetic resonance imaging (MRI) was positive for demyelinating lesions. Antibiotics, acyclovir and steroids have been given as treatment. DISCUSSION We suggest diagnostic criteria for diagnosis of PINS, considering the following parameters: neurological symptoms, timing of disease onset, blood and CSF laboratory tests, MRI imaging. CONCLUSIONS We propose criteria to guide clinician to diagnose PINS as definitive, probable or possible. Further studies are required to validate diagnostic criteria.
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Affiliation(s)
| | | | - Massimiliano Valeriani
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | - Laura Papetti
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | - Fabiana Ursitti
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | | | | | | | | | | | | | | | - Luigi Memo
- Italian Pediatric Society, Florence, Italy
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Li X, Hou C, Wu WL, Liang H, Zheng K, Zhang Y, Zeng Y, Chen L, Zhu H, Tian Y, Gao Y, Peng B, Yang S, Wang X, Ning S, Liao Y, Lin H, Chen WX. Pediatric anti-N-methyl-d-aspartate receptor encephalitis in southern China: Analysis of 111 cases. J Neuroimmunol 2021; 352:577479. [PMID: 33486307 DOI: 10.1016/j.jneuroim.2021.577479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the clinical features of children diagnosed with anti-NMDAR encephalitis in southern China. METHODS Clinical data of children diagnosed with anti-NMDAR encephalitis from October 2014 to June 2020 from one national regional medical center were analyzed. Neurological disability was assessed by modified Rankin Scale (mRS) throughout the course of disease. RESULTS 111 children (M/F = 49/62; mean onset age = 6.8 y) with anti-NMDAR encephalitis were involved. Prodromal events occurred in 34.2% of patients with infectious events being the most common. Seizure was the most common initial symptom, though movement disorder served as the most common event throughout the course of disease. 9.9% of patients had overlapped with other neuronal autoantibodies. Electroencephalogram showed abnormalities with slow wave (100.0%), epileptic discharge (31.5%) and delta brush (8.1%) respectively. 41.4% of patients had abnormal brain MRI, with focal lesions being the most common. None patients had tumor. 80.9% of patients had good response to first line therapy (steroid plus immunoglobulin), while 14 patients accepted second-line therapy (Rituximab) and all had a good response. Boys were significantly more likely to need more course of steroid. 13.8% of patients relapsed. 2 male patients died. mRS score was significantly improved after treatment. 51.4% of patients had a full recovery and 81.7% had mRS score ≤ 2. The median mRS score of boys after treatment was higher than that of girls. Non-infectious prodromal event, past medical history, perivascular lesions in brain MRI, hospital stay, initial mRS score higher than 3, and RTX treatment were independent risk factors associated with poor prognosis, defined as mRS score > 2. CONCLUSION Of pediatric anti-NMDAR encephalitis in southern China: median onset age around 7 years; girls more common; boys might have poor outcome than girls; seizure or movement disorder respectively being most common onset or course symptom; a few overlapped with other neuronal autoantibodies; rare combined with tumor; most had a good response to immunotherapy and a good prognosis; relapse rate relatively high; fatality rate relatively low; some risk factors associated with poor prognosis.
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Affiliation(s)
- Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Wen-Lin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Huici Liang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Lianfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Sida Yang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Xiuying Wang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Shuyao Ning
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Yinting Liao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Haisheng Lin
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jin Sui Road, 510623 Guangzhou, Guangdong Province, PR China.
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Cao L, Ren L, Huang X. Clinical analysis of a patient simultaneously positive for antibodies of myelin oligodendrocyte glycoprotein and anti-N-methyl-D-aspartate receptor: A case report. Medicine (Baltimore) 2021; 100:e24234. [PMID: 33429822 PMCID: PMC7793424 DOI: 10.1097/md.0000000000024234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/17/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Myelin oligodendrocyte glycoprotein (MOG) antibody (MOG-Ab) disease (MOG-AD) is a type of demyelinating disease of the central nervous system characterized by a high frequency of optic neuritis (ON) attacks. anti-Nmethyl-D-aspartate receptor (NMDAR) encephalitis (anti-NMDARe) is an autoimmune disorder characterized by memory deficits, conscious disturbance, and seizures. Cases of simultaneous occurrence of MOG-Ab and anti-NMDARe antibody (anti-NMDARe-Ab) are rarely reported and could be mistaken for overlapping MOG-antibody disease (MOG-AD) and NMDARe. The diagnosis of such patients is challenging. PATIENT CONCERNS We report the case of a 37-year-old man who presented with recurrent headaches for 3 months and worsening symptoms over 2 weeks. He had a history of ON. He had a generalized seizure after 7 days in the hospital. DIAGNOSIS Brain magnetic resonance imaging (MRI) and cerebrospinal fluid tests showed no apparent abnormalities. Repeat MRI showed slight lesions 7 days later, and cerebrospinal fluid tests showed the simultaneous occurrence of MOG-Ab and anti-NMDARe-Ab. INTERVENTIONS He completely recovered after treatment with low doses of oral corticosteroids. OUTCOMES Two months and 2 years follow-up showed that his condition was stable. LESSONS The co-occurrence of MOG-Ab and anti-NMDAR-Ab does not indicate the co-occurrence of MOG-AD and anti-NMDARe. Laboratory findings should be combined with the clinical features to achieve an accurate and suitable diagnosis.
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Affiliation(s)
- Liming Cao
- Department of Neurology, The 3rd Affiliated Hospital of Shenzhen University
- Department of Neurology, Shenzhen University First Affiliated Hospital
| | - Lijie Ren
- Department of Neurology, Shenzhen University First Affiliated Hospital
- Department of Neurology, Shenzhen Second People's Hospital
| | - Xuming Huang
- Department of Gastroenterology, Shenzhen Shiyan People's Hospital, Shenzhen, China
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18
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Nepal G, Shing YK, Yadav JK, Rehrig JH, Ojha R, Huang DY, Gajurel BP. Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis. Acta Neurol Scand 2020; 142:449-459. [PMID: 32484900 DOI: 10.1111/ane.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE. METHODS This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment. RESULTS Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease. CONCLUSION Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Yow K. Shing
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Jayant K. Yadav
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Jessica H. Rehrig
- University of New England College of Osteopathic Medicine Biddeford ME USA
| | - Rajeev Ojha
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Dong Y Huang
- Department of Neurology Shanghai East Hospital of Tongji University School of Medicine Shanghai China
| | - Bikram P. Gajurel
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
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19
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Hébert J, Riche B, Vogrig A, Muñiz-Castrillo S, Joubert B, Picard G, Rogemond V, Psimaras D, Alentorn A, Berzero G, Desestret V, Rabilloud M, Honnorat J. Epidemiology of paraneoplastic neurologic syndromes and autoimmune encephalitides in France. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/6/e883. [PMID: 32847939 PMCID: PMC7455315 DOI: 10.1212/nxi.0000000000000883] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/17/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the observed and expected incidence rates of paraneoplastic neurologic syndromes (PNSs) and autoimmune encephalitides (AEs) diagnosed in France between 2016 and 2018, we conducted a population-based epidemiologic study. METHODS Observed incidence rates were stratified by sex, age groups, region of care, year of diagnosis, and disease subgroups. National expected incidence rates were calculated based on rates obtained in the area directly adjacent to the Reference Center using a mixed Poisson model and compared with observed incidence rates. RESULTS Six hundred thirty-two patients with definite PNS or AE met the inclusion criteria. The observed incidence rate of definite PNS and AE in France was 3.2 per million person-years (CI95%: 2.9-3.4) compared with an expected incidence rate of 7.1 per million person-years (CI95%: 3.9-11.4). The national observed incidence rate for the antibody-positive AE subgroup increased from 1.4 per million person-years (CI95%: 1.2-1.7) in 2016 to 2.1 per million person-years (CI95%: 1.7-2.4) in 2018, thus surpassing the incidence rate of classical PNS (1.2 per million person-years [CI95%: 1.0-1.5]) of 2018. CONCLUSIONS There was a significant widespread year-to-year increase in the incidence of diagnoses registered with the Reference Center for all subgroups of PNS and AE studied. The national observed incidence rate is likely underestimated due to underdiagnosis and underreporting.
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Affiliation(s)
- Julien Hébert
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Benjamin Riche
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Alberto Vogrig
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Sergio Muñiz-Castrillo
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Bastien Joubert
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Géraldine Picard
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Véronique Rogemond
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Dimitri Psimaras
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Agusti Alentorn
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Giulia Berzero
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Virginie Desestret
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Muriel Rabilloud
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jérôme Honnorat
- From the Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), Hospices Civils de Lyon, Lyon, France; SynatAc Team (J. Hébert, A.V., S.M.-C., B.J., G.P., V.R., V.D., J. Honnorat), NeuroMyoGene Institute, INSERM U1217-CNRS UMR5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Université de Lyon (J. Hébert, B.R., M.R.), Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS UMR, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France; Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique (J. Hébert), Faculté de Médecine, Sorbonne Université, Paris, France; AP-HP (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2-Mazarin et Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS, Paris, France; Inserm U 975 (D.P., G.B.), CNRS, UMR, Paris, France; and Centre de Compétence des Syndromes Neurologiques Paraneoplasiques et Encéphalites Autoimmunes (D.P., G.B.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Ekinci F, Yildizdas D, Horoz OO, Yontem A, Gul Mert G. Pulmonary embolism complicated the course of anti-N-methyl-D aspartate receptor encephalitis in a pediatric intensive care unit setting: a case report. Postgrad Med 2020; 133:102-107. [PMID: 32703058 DOI: 10.1080/00325481.2020.1801031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, an autoimmune neurological disorder resultant from the autoantibodies directed to the NR1 subunit of the NMDAR, is mainly characterized by neuropsychiatric symptoms, including behavior changes, paranoia, delusions, epileptic seizures, movement disorders, aphasia, insomnia, dysautonomia, and altered consciousness. Pulmonary embolism (PE) presents with pleuritic chest pain, hemoptysis, and respiratory distress by obstruction of the pulmonary circulation. Unlike adults, pediatric PE usually related to obvious risk factors, including central venous line, malignancy, lupus erythematosus, renal disease, congenital thrombophilia, surgery, and major trauma. Besides, PE has rarely been encountered in adult patients with anti-NMDAR encephalitis even in the absence of these risk factors. CASE PRESENTATION A 16-year-old male patient, with acute psychosis, epileptic seizure, and altered consciousness, was diagnosed as having anti-NMDAR encephalitis and treated by intravenous immunoglobulin and high-dose pulse intravenous methylprednisolone. During follow-up, on the 11th day of hospitalization, the disease course was complicated by the occurrence of pulmonary embolism, presenting with acute onset respiratory distress and the need for supplementary oxygen treatment. PE improved with low-molecular-weight heparin treatment. CONCLUSION Pulmonary embolism should be kept in mind as a possible cause of respiratory insufficiency in pediatric anti-NMDAR encephalitis patients along with altered consciousness, breathing instability, hypersalivation, status epilepticus or dystonia, and their treatment.
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Affiliation(s)
- Faruk Ekinci
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine , Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine , Adana, Turkey
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine , Adana, Turkey
| | - Ahmet Yontem
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine , Adana, Turkey
| | - Gulen Gul Mert
- Department of Pediatric Neurology, Cukurova University Faculty of Medicine , Adana, Turkey
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Vogrig A, Muñiz-Castrillo S, Desestret V, Joubert B, Honnorat J. Pathophysiology of paraneoplastic and autoimmune encephalitis: genes, infections, and checkpoint inhibitors. Ther Adv Neurol Disord 2020; 13:1756286420932797. [PMID: 32636932 PMCID: PMC7318829 DOI: 10.1177/1756286420932797] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/17/2020] [Indexed: 12/14/2022] Open
Abstract
Paraneoplastic neurological syndromes (PNSs) are rare complications of systemic cancers that can affect all parts of the central and/or peripheral nervous system. A body of experimental and clinical data has demonstrated that the pathogenesis of PNSs is immune-mediated. Nevertheless, the mechanisms leading to immune tolerance breakdown in these conditions remain to be elucidated. Despite their rarity, PNSs offer a unique perspective to understand the complex interplay between cancer immunity, effect of immune checkpoint inhibitors (ICIs), and mechanisms underlying the attack of neurons in antibody-mediated neurological disorders, with potentially relevant therapeutic implications. In particular, it is reported that ICI treatment can unleash PNSs and that the immunopathological features of PNS-related tumors are distinctive, showing prominent tumor-infiltrating lymphocytes and germinal center reactions. Intriguingly, similar pathological substrates have gained further attention as potential biomarkers of ICI-sensitivity and oncological prognosis. Moreover, the genetic analysis of PNS-associated tumors has revealed specific molecular signatures and mutations in genes encoding onconeural proteins, leading to the production of highly immunogenic neoantigens. Other than PNSs, autoimmune encephalitides (AEs) comprise a recently described group of disorders characterized by prominent neuropsychiatric symptoms, diverse antibody spectrum, and less tight association with cancer. Other triggering factors seem to be involved in AEs. Recent data have shed light on the importance of preceding infections (in particular, herpes simplex virus encephalitis) in inducing neurological autoimmune disorders in susceptible individuals (those with a selective deficiency in the innate immune system). In addition, in some AEs (e.g. LGI1-antibody encephalitis) an association with specific host-related factors [e.g., human leukocyte antigen (HLA)] was clearly demonstrated. We provide herein a comprehensive review of the most recent findings in the field of PNSs and AEs, with particular focus on their triggering factors and immunopathogenesis.
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Affiliation(s)
- Alberto Vogrig
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Sergio Muñiz-Castrillo
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Virginie Desestret
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Bastien Joubert
- French Reference Center for Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Centre de Référence National pour les Syndromes Neurologiques Paranéoplasiques, Hôpital Neurologique, 59 Boulevard Pinel, Bron Cedex, 69677, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, Université de Lyon, Lyon, France
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Mo Y, Wang L, Zhu L, Li F, Yu G, Luo Y, Ni M. Analysis of Risk Factors for a Poor Prognosis in Patients with Anti- N-Methyl-D-Aspartate Receptor Encephalitis and Construction of a Prognostic Composite Score. J Clin Neurol 2020; 16:438-447. [PMID: 32657065 PMCID: PMC7354980 DOI: 10.3988/jcn.2020.16.3.438] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most-common form of autoimmune encephalitis, but its early diagnosis is challenging. This study aimed to identify the risk factors for a poor prognosis in anti-NMDAR encephalitis and construct a prognostic composite score for obtaining earlier predictions of a poor prognosis. METHODS We retrospectively analyzed the clinical data, laboratory indexes, imaging findings, and electroencephalogram (EEG) data of 60 patients with anti-NMDAR encephalitis. The modified Rankin Scale (mRS) scores of patients were collected when they were discharged from the hospital. The mRS scores were used to divide the patients into two groups, with mRS scores of 3-6 defined as a poor prognosis. Logistic regression analysis was used to analyze independent risk factors related to a poor prognosis. RESULTS This study found that 23 (38.3%) and 37 (61.7%) patients had good and poor prognoses, respectively. Logistic regression analysis showed that age, disturbance of consciousness at admission, and ≥50% slow waves on the EEG were significantly associated with patient outcomes. An age, consciousness, and slow waves (ACS) composite score was constructed to predict the prognosis of patients with anti-NMDAR encephalitis at an early stage based on regression coefficients. CONCLUSIONS Age, disturbance of consciousness at admission, and ≥50% slow waves on the EEG were independent risk factors for a poor prognosis. The ACS prognostic composite score could play a role in facilitating early predictions of the prognosis of anti-NMDAR encephalitis.
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Affiliation(s)
- Yejia Mo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Li Wang
- Department of Biology and Biochemistry, Center for Nuclear Receptors and Cell Signaling, University of Houston, Houston, TX, USA
| | - Libo Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Gang Yu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Yetao Luo
- Department of Biostatistics, School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Meng Ni
- Department of the First Clinical Medicine, Chongqing Medical University, Chongqing, China
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Zhang J, Ji T, Chen Q, Jiang Y, Cheng H, Zheng P, Ma W, Lei T, Zhang Y, Jin Y, Wei C, Wu Y, Chang X, Bao X, Zhang Y, Xiong H, Ji X, Feng S, Ren H, Yang J, Jiang Y. Pediatric Autoimmune Encephalitis: Case Series From Two Chinese Tertiary Pediatric Neurology Centers. Front Neurol 2019; 10:906. [PMID: 31507515 PMCID: PMC6714292 DOI: 10.3389/fneur.2019.00906] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 08/05/2019] [Indexed: 12/15/2022] Open
Abstract
Background and purpose: We retrospectively analyzed the clinical characteristics of children with autoimmune encephalitis (AE) in two Chinese tertiary pediatric neurology centers. We also compared anti-NMDAR encephalitis with and without co-positive MOG antibody, as well as specific autoantibody-positive AE and autoantibody-negative but probable AE. Methods: A retrospective study of children (0-18 years old) with AE in Peking University First Hospital and Children's Hospital Affiliated to Capital Institute of Pediatrics was carried out from May 2012 to January 2017. Demographics, clinical features, laboratory, and imaging findings, outcome, and co-positivity with MOG antibody were analyzed. Results: A total of 103 children had AE, 89 (86.4%) had anti-NMDAR encephalitis, 2 (1.9%) had anti-LGI1 encephalitis, 1 (0.9%) had anti-CASPR2 encephalitis, and 11 (10.7%) were diagnosed as autoantibody-negative but probable AE. Among the 89 children with anti-NMDAR encephalitis, 35 were males and 54 were females. The follow-up time was 1-3 years. A total of 15 cases (15/89, 16.9%) with anti-NMDAR encephalitis had co-positive MOG antibody (serum or cerebrospinal fluid or both). These patients were more likely to experience relapse later in life (P = 0.014). We had two cases with anti-LGI1 encephalitis, that is, one with sleep disorder onset, and the other one with seizure onset, both of whom recovered after treatment. One case with anti-CASPR2 encephalitis was treated with an antiepileptic drug and fully recovered. There were 11 cases diagnosed as autoantibody-negative but probable AE who had relatively poorer outcome than those with autoantibody-positive AE (15.2%, 14/89). However, the difference was not significant (P = 0.08). Only one 12-year-old girl with NMDAR-antibody AE had ovarian teratoma. Conclusion: Most subjects with AE in our Chinese cohort had anti-NMDAR AE, which had relatively good prognosis. Children with anti-LGI1 or anti-CASPR2 encephalitis were rare and showed good response on immunotherapy. Co-positive MOG antibody was relatively common in anti-NMDAR encephalitis, which was related to high relapse rate. In our study, the prognosis of autoantibody-negative but probable AE seemed worse than that of specific autoantibody-positive AE.
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Affiliation(s)
- Jianzhao Zhang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Taoyun Ji
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Qian Chen
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Yanan Jiang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Huan Cheng
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Ping Zheng
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Wenqiang Ma
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Ting Lei
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Yao Zhang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Yiwen Jin
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Cuijie Wei
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Ye Wu
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Xingzhi Chang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Xinhua Bao
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Yuehua Zhang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Hui Xiong
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
| | - Xinna Ji
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Shuo Feng
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Jian Yang
- Department of Pediatric Neurology, Children's Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
| | - Yuwu Jiang
- Division of Pediatric Neurology, Pediatrics Department, Peking University First Hospital, Beijing, China
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Pruetarat N, Netbaramee W, Pattharathitikul S, Veeravigrom M. Clinical manifestations, treatment outcomes, and prognostic factors of pediatric anti-NMDAR encephalitis in tertiary care hospitals: A multicenter retrospective/prospective cohort study. Brain Dev 2019; 41:436-442. [PMID: 30639077 DOI: 10.1016/j.braindev.2018.12.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/20/2018] [Accepted: 12/27/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Anti-NMDAR encephalitis is an acute autoimmune neurological disorder that is increasingly recognized in pediatric populations. Several studies of the disorder have been conducted worldwide but there are few publications in Thailand. Here, we describe the clinical manifestations, treatment outcomes, and prognostic factors in children with anti-NMDAR encephalitis. METHODS Between January 2007 and September 2017, we conducted a retrospective/prospective cohort study of children diagnosed with anti-NMDAR encephalitis from three tertiary care hospitals in Thailand: King Chulalongkorn Memorial Hospital, Chonburi Hospital, and Prapokklao Hospital. We assessed the Modified Rankin Score (mRS) score for each participant to measure severity of disease and treatment outcome at baseline, 12, and 24 months. RESULTS We recruited 14 participants (1-13 years with median age 8.4 years). Participants were followed up for a median of 20.5 months. Clinical manifestations included behavioral dysfunction (100%), movement disorder (93%), speech disorder (79%), sleep disorder (79%), and seizures (79%). All patients received first-line immunotherapy (corticosteroids: 100%, intravenous immunoglobulin: 79%, plasma exchange: 21%). Second-line immunotherapy (cyclophosphamide) was administered to 57% of patients. During the first 12 months, 8 patients (62%) achieved a good outcome (mRS ≤ 2). At 24 months, 9 patients (81%) had achieved a good outcome. Altered consciousness and central hypoventilation were predictors of poor outcome. (p < 0.05). CONCLUSIONS We observed similar clinical manifestation of anti-NMDAR encephalitis in Thai children to those reported in other countries. Furthermore, the percentage of patients with good outcomes in our study was comparable with previous studies. Further studies are required to investigate other populations in other regions of Thailand.
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Affiliation(s)
- Napa Pruetarat
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand
| | | | | | - Montida Veeravigrom
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand; Division of Neurology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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A review of EEG in anti-NMDA receptor encephalitis. J Neuroimmunol 2019; 332:64-68. [PMID: 30959339 DOI: 10.1016/j.jneuroim.2019.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 03/16/2019] [Accepted: 03/17/2019] [Indexed: 12/21/2022]
Abstract
Anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is common among autoimmune encephalitides (AE) and can present with protean features and nonspecific laboratory and neuroimaging results. Antibody testing is specific, but results are often delayed, and prompt diagnosis and treatment is vital given associated morbidity and mortality. Electroencephalography (EEG) may be a useful tool given ease of performance and short turn-around time for results. As such, we performed a systematic review of the literature on anti-NMDARE and EEG characteristics. We found that EEG is often pathologic in anti-NMDAR encephalitis, though at times nonspecific. A stronger focus on common EEG features in patient with this type of encephalitis and an effort to identify when these features are present in the course of the disease may allow for improved diagnosis, description and differentiation of anti-NMDARE.
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Clinical variability of children with anti-N-methyl-D-aspartate receptor encephalitis in southern Brazil: a cases series and review of the literature. Neurol Sci 2018; 40:351-356. [PMID: 30460460 DOI: 10.1007/s10072-018-3648-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/13/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated disease of the central nervous system (CNS). The aim of this study was to describe the variability of clinical presentation in anti-NMDAR encephalitis, treatment and outcomes in a case series of children and adolescents. METHODS Retrospectively analyse patients diagnosed with anti-NMDAR encephalitis, from 2010 to 2018. RESULTS The study population consisted of nine children with anti-NMDAR encephalitis from southern Brazil, six females and three males, aged 5 months to 16 years (mean 5 years). The time of follow-up varied between 1 and 7 years, with a mean of 3 years. The most frequent first manifestation consisted of seizures. All patients described had psychiatric symptoms and a wide spectrum of neurologic findings. Five patients had unilateral symptoms. Magnetic resonance imaging and electroencephalogram were normal in most patients. Cerebrospinal fluid pleocytosis occurred in five patients. All patients were administered immunoglobulin and/or steroids. Seven patients (78%) required cyclophosphamide and/or rituximab. Almost half of the patients fully recovered from all symptoms. CONCLUSIONS A wide variety of symptoms were observed in this study and, although unilateral symptoms are rarely reported in the literature, a high frequency was observed among Brazilian children. Alternatives to first-line therapy should be considered in patients with clinical suspicion, even if they have not had a good response with first-line therapy.
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Armangue T, Spatola M, Vlagea A, Mattozzi S, Cárceles-Cordon M, Martinez-Heras E, Llufriu S, Muchart J, Erro ME, Abraira L, Moris G, Monros-Giménez L, Corral-Corral Í, Montejo C, Toledo M, Bataller L, Secondi G, Ariño H, Martínez-Hernández E, Juan M, Marcos MA, Alsina L, Saiz A, Rosenfeld MR, Graus F, Dalmau J. Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis. Lancet Neurol 2018; 17:760-772. [PMID: 30049614 DOI: 10.1016/s1474-4422(18)30244-8] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/04/2018] [Accepted: 06/12/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Herpes simplex encephalitis can trigger autoimmune encephalitis that leads to neurological worsening. We aimed to assess the frequency, symptoms, risk factors, and outcomes of this complication. METHODS We did a prospective observational study and retrospective analysis. In the prospective observational part of this study, we included patients with herpes simplex encephalitis diagnosed by neurologists, paediatricians, or infectious disease specialists in 19 secondary and tertiary Spanish centres (Cohort A). Outpatient follow-up was at 2, 6, and 12 months from onset of herpes simplex encephalitis. We studied another group of patients retrospectively, when they developed autoimmune encephalitis after herpes simplex encephalitis (Cohort B). We compared demographics and clinical features of patients who developed autoimmune encephalitis with those who did not, and in patients who developed autoimmune encephalitis we compared these features by age group (patients ≤4 years compared with patients >4 years). We also used multivariable binary logistic regression models to assess risk factors for autoimmune encephalitis after herpes simplex encephalitis. FINDINGS Between Jan 1, 2014, and Oct 31, 2017, 54 patients with herpes simplex encephalitis were recruited to Cohort A, and 51 were included in the analysis (median age 50 years [IQR 5-68]). At onset of herpes simplex encephalitis, none of the 51 patients had antibodies to neuronal antigens; during follow-up, 14 (27%) patients developed autoimmune encephalitis and all 14 (100%) had neuronal antibodies (nine [64%] had NMDA receptor [NMDAR] antibodies and five [36%] had other antibodies) at or before onset of symptoms. The other 37 patients did not develop autoimmune encephalitis, although 11 (30%) developed antibodies (n=3 to NMDAR, n=8 to unknown antigens; p<0·001). Antibody detection within 3 weeks of herpes simplex encephalitis was a risk factor for autoimmune encephalitis (odds ratio [OR] 11·5, 95% CI 2·7-48·8; p<0·001). Between Oct 7, 2011, and Oct 31, 2017, there were 48 patients in Cohort B with new-onset or worsening neurological symptoms not caused by herpes simplex virus reactivation (median age 8·8 years [IQR 1·1-44·2]; n=27 male); 44 (92%) patients had antibody-confirmed autoimmune encephalitis (34 had NMDAR antibodies and ten had other antibodies). In both cohorts (n=58 patients with antibody-confirmed autoimmune encephalitis), patients older than 4 years frequently presented with psychosis (18 [58%] of 31; younger children not assessable). Compared with patients older than 4 years, patients aged 4 years or younger (n=27) were more likely to have shorter intervals between onset of herpes simplex encephalitis and onset of autoimmune encephalitis (median 26 days [IQR 24-32] vs 43 days [25-54]; p=0·0073), choreoathetosis (27 [100%] of 27 vs 0 of 31; p<0·001), decreased level of consciousness (26 [96%] of 27 vs seven [23%] of 31; p<0·001), NMDAR antibodies (24 [89%] of 27 vs 19 [61%] of 31; p=0·033), and worse outcome at 1 year (median modified Rankin Scale 4 [IQR 4-4] vs 2 [2-3]; p<0·0010; seizures 12 [63%] of 19 vs three [13%] of 23; p=0·001). INTERPRETATION The results of our prospective study show that autoimmune encephalitis occurred in 27% of patients with herpes simplex encephalitis. It was associated with development of neuronal antibodies and usually presented within 2 months after treatment of herpes simplex encephalitis; the symptoms were age-dependent, and the neurological outcome was worse in young children. Prompt diagnosis is important because patients, primarily those older than 4 years, can respond to immunotherapy. FUNDING Mutua Madrileña Foundation, Fondation de l'Université de Lausanne et Centre Hospitalier Universitaire Vaudois, Instituto Carlos III, CIBERER, National Institutes of Health, Generalitat de Catalunya, Fundació CELLEX.
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Affiliation(s)
- Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Neurology Department, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Marianna Spatola
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; University of Lausanne, Lausanne, Switzerland
| | - Alexandru Vlagea
- Immunology Department, Centre of Biomedical Diagnosis, Hospital Clínic, University of Barcelona, Barcelona, Spain; Functional Unit of Clinical Immunology, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Simone Mattozzi
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Section of Child Neuropsychiatry, Department of Medical Surgical and Experimental Medicine, University of Sassari (Sassari), Italy
| | - Marc Cárceles-Cordon
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eloy Martinez-Heras
- Laboratory of Advanced Imaging in Neuroimmunological Diseases (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Sara Llufriu
- Laboratory of Advanced Imaging in Neuroimmunological Diseases (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jordi Muchart
- Department of Radiology, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - María Elena Erro
- Department of Neurology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Laura Abraira
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - German Moris
- Department of Neurology, Hospital Central de Asturias, Oviedo, Spain
| | - Luis Monros-Giménez
- Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Carmen Montejo
- Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Manuel Toledo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Luis Bataller
- Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Gabriela Secondi
- Pediatric Neuroimmunology Unit, Neurology Department, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Helena Ariño
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eugenia Martínez-Hernández
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Manel Juan
- Immunology Department, Centre of Biomedical Diagnosis, Hospital Clínic, University of Barcelona, Barcelona, Spain; Functional Unit of Clinical Immunology, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Maria Angeles Marcos
- Microbiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Laia Alsina
- Functional Unit of Clinical Immunology, Research Institute of Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Albert Saiz
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Myrna R Rosenfeld
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, PA, USA
| | - Francesc Graus
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain; Service of Neurology, Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, PA, USA; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
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