Anti-NMDAR encephalitis followed by seropositive neuromyelitis optica spectrum disorder: A case report and literature review

Optic neuritis associated with seronegative autoimmune encephalitis: a case report

Optic neuritis is an inflammatory demyelinating disorder that primarily affects the optic nerve and is often associated with multiple sclerosis. While it is rare for optic neuritis to be accompanied by autoimmune encephalitis, it can occur in some cases. A 65-year-old woman with bipolar disorder presented with a progressively altered mentality. Magnetic resonance imaging of the brain showed no definite abnormal findings. Electroencephalography revealed nonconvulsive status epilepticus. Cerebrospinal fluid study and autoimmune and paraneoplastic encephalitis antibodies were negative. The patient was diagnosed with seronegative autoimmune encephalitis and treated with methylprednisolone, intravenous immunoglobulin, and rituximab. Her condition gradually improved except for persistent blindness on the left side. This case highlights the importance of considering autoimmune encephalitis even in the absence of identifiable pathogenic antibodies when clinical manifestations and response to immunotherapy support such a diagnosis.

Clinical Characteristics of Anti-N-Methyl-d-Aspartate Receptor Encephalitis Overlapping with Demyelinating Diseases: A Review

Anti-N-methyl-d-aspartate receptor encephalitis (NMDARe), a common autoimmune encephalitis, can be accompanied by demyelinating disorders, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). To compare the clinical characteristics of patients with different overlapping syndromes, we searched the PubMed database and performed a systematic review. Of the 79 patients with overlapping syndromes, 15 had MS, 18 had aquaporin-4-antibody-positive NMOSD (AQP4-Ab-positive NMOSD), and 46 had MOGAD. Compared with classical NMDARe, overlapping syndromes showed atypical symptoms, such as limb weakness, sensory disturbance, and visual impairments in addition to the main symptoms of NMDARe and a lower ratio of ovarian teratoma. Patients with MOGAD overlap were the youngest, while patients with MS and AQP4-Ab-positive NMOSD overlap tended to be older than patients with classical NMDARe. A majority of patients with NMDARe who overlapped with MS or AQP4-Ab-positive NMOSD were female, but this was not the case for patients overlapped with MOGAD. When NMDARe and demyelinating diseases occurred sequentially, the interval was the longest in patients with NMDARe overlapped with MS. A favorable outcome was observed in patients overlapping with MOGAD, but no robust comparison can be drawn with the patients overlapping with AQP4-Ab-positive NMOSD and MS regarding the small number of available data. The long-term prognosis of overlapping syndromes needs further investigation.

Optic neuritis associated with anti-NMDA receptor antibody in the remission phase of anti-NMDA receptor encephalitis

Optic neuritis is an inflammatory demyelinating disorder of the central nervous system. Anti-NMDA receptor (NMDAR) antibodies encephalitis is also mediated by the inappropriate immunological response. We report a girl who was readmitted because of unilateral eye pain and vision impairment in the remission period of anti-NMDAR encephalitis. Based on the limited available literature on the treatment of optic neuritis associated with anti-NMDA receptor antibody, she was treated with a combination of corticosteroids and intravenous immunoglobulin with clinical improvement. Optic neuritis in the remission phase of anti-N-methyl-D-aspartate receptor encephalitis remains relatively uncommon. It is important to document and follow these patients to understand the pathogenesis of optic neuritis in the setting of anti-NMDAR encephalitis and formulate effective therapeutic strategies.

Long-term persistence of NMDAR antibodies after encephalitis with de novo occurrence of demyelinating disorder

The issue of persistence of NMDAR antibodies after encephalitis is not fully elucidated and their relationship with demyelinating disorders has been suggested. A female patient showed at the age of 18 an acute neurological disorder (with psychiatric symptoms, focal seizures, orofacial dyskinesias and hypoventilation requiring ventilatory support) clinically mimicking anti-NMDAR encephalitis. At that time specific laboratory tests were not available, CSF revealed oligoclonal bands and MRI was negative. The patient had full recovery after first line immunotherapy (i.v. steroids and immunoglobulins). Fifteen years later, at the age of 33, she was hospitalized with subacute right hemiparesis and MRI disclosed multiple T2 hyperintensities in the white matter, one of them in the left midbrain showing contrast enhancement. Serum and CSF NMDAR antibodies were positive while MOG and AQP4 antibodies were negative. Intravenous methylprednisolone led to complete recovery. This case report provides evidence of a long-term persistence of NMDAR antibodies even 15 years after the encephalitis and raises the suspicion of a possible causal relationship between NMDAR antibodies and demyelinating disorders in the form of multiple sclerosis.

Anti-NMDA receptor encephalitis concomitant with myelin oligodendrocyte glycoprotein antibody diseases: A retrospective observational study

Anti-N-methyl-D-aspartate receptor encephalitis (NMDARe) can coexist with myelin oligodendrocyte glycoprotein antibody (MOG-ab) disease.To characterize MOG-ab disease during NMDARe, we analyzed all the patients with MOG-ab disease and NMDARe from our hospital from December 2018 to December 2019 and data from a systematical review of previously published reports. Details of the patients identified were summarized and literature was reviewed.Four of thirty (14.2%) patients with anti-NMDARe had overlapping MOG-ab disease in our department. Analyze together with previously reported cases. Thirty-two NMDARe patients had overlapping MOG-ab disease. The onset age ranged from 3 to 48 years. Twenty-four patients (74%) developed abnormal behavior or cognitive dysfunction during the episodes of anti-NMDARe. None of these patients had tumors. 84% (27/32) patients received high doses of steroids as first-line immunotherapy and 28% (9/32) received mycophenolate mofetil (MMF) to prevent relapse. Twenty-six of twenty-seven (96%) had a good outcome.Steroids are the most common first-line immunotherapies in NMDARe overlapping MOG-ab disease. Most of the NMDARe patients overlapping MOG-ab disease have a good prognosis.

[Anti-NMDAR encephalitis associated with relapsing optic neuritis]

Autoimmune encephalitis with antibodies to NMDA receptors (anti-NMDAR encephalitis), is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.

Imaging of Neuromyelitis Optica Spectrum Disorders

Neuromyelitis optica (NMO) is a rare and chronic disabling autoimmune astrocytopathy of the central nervous system. Current advances regarding aquaporin-4 antibody function facilitate the understanding of clinical manifestations and imaging findings beyond optic neuritis and transverse myelitis. The current definition of NMO spectrum disorder (NMOSD) includes both aquaporin-4-IgG seropositive and seronegative patients who present with characteristic findings. This review will briefly summarize the pathophysiology and the latest NMOSD diagnostic criteria and focus on the NMOSD imaging findings and its differential diagnosis.

Clinical analysis of anti-NMDAR encephalitis combined with MOG antibody in children

OBJECTIVE

To analyze the clinical features in children with anti-NMDAR encephalitis combined with myelin oligodendrocyte glycoprotein antibody (MOG ab).

METHODS

Clinical data of 7 children with anti-NMDAR encephalitis combined with MOG ab(+) were collected in Guangzhou Women and Children's Medical Center from January, 2016 to June, 2019. Children with NMDAR ab(+)/MOG ab(-) and MOG ab(+)/NMDAR ab(-) were randomly selected as controls.

RESULTS

Onset age was 6.0 (IQR 5.0-7.0) years old, male to female was 2:5. Prominent symptoms include abnormal mental behavior (7/7), sleep disorder (6/7), speech disorder (6/7), involuntary movement (4/7) and paralysis (4/7). There were significant differences between NMDAR ab(+)/MOG ab(+) group versus MOG ab(+)/NMDAR ab(-) and NMDAR ab(+)/MOG ab(-) group versus MOG ab(+)/NMDAR ab(-) group (P< 0.0167, Fisher exact tests) in abnormal mental behavior, sleep disorder, speech disorder and involuntary movement. 1 case developed anti-NMDAR encephalitis 1 year after recovery from MOG ab related acute disseminated encephalomyelitis (ADEM). 4 cases developed anti-NMDAR encephalitis and MOG ab related ADEM simultaneously, with 2 cases relapsed. 2 cases were anti-NMDAR encephalitis with only MOG ab positive. In terms of MRI, there were differences in subcortical white matter, basal ganglia and brainstem (P < 0.0167, Fisher exact tests) between NMDAR ab(+)/MOG ab(+) group versus NMDAR ab(+)/MOG ab(-) (P < 0.0001) and NMDAR ab(+)/MOG ab(-) group versus MOG ab(+)/NMDAR ab(-) group(P<0.0001). There were significant differences in MOG antibody titer (Z = -=2.03, P = 0.042) and duration (Z = -1.97, P = 0.049) between relapsed and non-relapsed patients. 3 cases had neurological sequelae. The differences of NMDAR antibody titer (Z = -2.22, P = 0.026) and duration (Z = -2.18, P = 0.029) were significant between patients with and without neurological sequelae.

CONCLUSION

NMDAR and MOG antibodies can coexist in children with autoimmune encephalitis. Double antibody positive subjects had more overlaps in clinical manifestations with NMDAR encephalitis, and more overlaps in MRI changes with MOG ab related disease. Higher persistent MOG antibody titer may indicate recurrence, while higher persistent NMDAR antibodies titer may cause neurological sequelae.

[Anti-NMDAR encephalitis associated with relapsing optic neuritis: a case report and differential diagnosis]

Autoimmune encephalitis with antibodies to NMDA receptors, or anti-NMDAR encephalitis, is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article presents the literature review and describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis, which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.

AQP4-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) coexisting with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis: A case report and literature review

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) can coexist with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Patients with overlapping Aquaporin 4 immunoglobulin G (AQP4-IgG)-seropositive NMOSD and anti-NMDAR encephalitis with positive NMDAR antibodies in the cerebrospinal fluid (CSF) are rare but should not be ignored.

METHODS

A unique case of NMOSD coexisting with anti-NMDAR encephalitis is presented. Case reports of AQP4-IgG-seropositive NMOSD overlapping with anti-NMDAR encephalitis with positive NMDAR antibodies in the CSF were reviewed.

RESULTS

A 61-year-old female presented with headache, blurred vision, dysuria, limb weakness, coma, respiratory failure, and hypotension. Brain magnetic resonance imaging (MRI) showed abnormal signals in the left temporal lobe, white matter around the bilateral ventricles, midbrain, medulla oblongata, cervical, and upper thoracic medulla. AQP4-IgG antibodies were positive in the serum and CSF. NMDAR antibodies were positive in the CSF. The patient's condition was stable following intravenous gamma globulin, corticosteroids, immunosuppressants, and symptomatic support treatments. Only a single met the criteria of NMOSD simultaneously coexisting with anti-NMDAR encephalitis in addition to our own case.

CONCLUSIONS

This case provides further evidence for the occurrence of NMOSD with AQP4-IgG-seropositive overlapping anti-NMDAR encephalitis in a Chinese patient. The mechanisms underlying the occurrence of double positive antibodies remains elusive. When NMOSD patients show unusual symptoms (abnormal behavior, prominent psychiatric manifestations, cognitive dysfunction, autonomic dysfunction), or atypical supratentorial lesions, the coexistence of anti-NMDAR encephalitis should be considered.

Autoimmune diseases associated with Neuromyelitis Optica Spectrum Disorders: A literature review

INTRODUCTION

Neuromyelitis Optica (NMO) is an autoimmune inflammatory demyelinating disease of the central nervous system (CNS) which predominantly involves optic nerves and spinal cord. Since the introduction of Neuromyelitis Optica Spectrum Disorders (NMOSD) as a separate entity, there have been many reports on its association with other disorders including systemic and organ-specific autoimmune diseases. Here, we reviewed other immune-mediated diseases associated with NMOSD and tried to categorize them.

METHODS

The present review was conducted using the PUBMED database based on papers from 1976 (i.e., since the first NMO comorbidity with SLE was reported) to 2017. We included all articles published in English. The keywords utilized included Neuromyelitis optica, Neuromyelitis Optica Spectrum Disorders, Devic's disease, in combination with comorbidity or comorbidities.

RESULTS

Diseases with immune-based pathogenesis are the most frequently reported co-morbidities associated with NMOSD, most of which are antibody-mediated diseases. According to literature, Sjogren's Syndrome (SS) and Systemic Lupus Erythematosus (SLE) are the most frequently reported diseases associated with NMOSD among systemic autoimmune diseases. Further, myasthenia gravis in neurological and autoimmune thyroid diseases in non-neurological organ-specific autoimmune diseases are the most reported comorbidities associated with NMOSD in the literature.

CONCLUSIONS

NMOSD may be associated with a variety of different types of autoimmune diseases. Therefore, systemic or laboratory signs which are not typical for NMOSD should be properly investigated to exclude other associated comorbidities. These comorbidities may affect the treatment strategy and may improve the patients' care and management.

Comparison of myelin oligodendrocyte glycoprotein (MOG)-antibody disease and AQP4-IgG-positive neuromyelitis optica spectrum disorder (NMOSD) when they co-exist with anti-NMDA (N-methyl-D-aspartate) receptor encephalitis

BACKGROUND

Myelin oligodendrocyte glycoprotein (MOG)-antibody (ab) disease and AQP4-IgG-positive neuromyelitis optica spectrum disorder (NMOSD) can co-exist with anti-NMDA (N-methyl-D-aspartate) receptor encephalitis (NMDARe).

OBJECTIVES

To characterize MOG-ab disease and AQP4-IgG-positive NMOSD during NMDARe.

METHODS

We analyzed all the patients with overlapping MOG-ab disease and NMDARe (MNOS) and patients with AQP4-IgG-positive NMOSD and NMDARe (ANOS) in our hospital and compared those data with data from systematically review of previously published reports.

RESULTS

In our cohorts, 11.9% patients with MOG-ab disease and 0.6% patients with NMOSD had overlapping NMDARe (P < 0.01). After treatment with steroids and/or intravenous immunoglobulin (IVIg), the median modified Rankin Scale (mRS) of the MNOS group decreased significantly during attacks associated with or without NMDARe (P < 0.01 for both), while that of the ANOS group did not (attack: P < 0.05; attack associated with NMDARe: P > 0.05). Analyzed together with previously reported cases, 6% patients with MNOS and 40% patients with ANOS also used rituximab or cyclophosphamide after steroids and/or IVIg (P < 0.05) during attacks associated with NMDARe.

CONCLUSION

Compared with NMOSD, MOG-ab disease may more commonly co-exist with NMDARe. MNOS patients respond better to steroids and IVIg than do ANOS patients during attacks associated with NMDARe.

Anti-NMDA Receptor Encephalitis: Clinical Features and Basic Mechanisms

In slightly more than 10 years, anti-NMDA receptor (NMDAR) encephalitis has changed from a rare paraneoplastic syndrome to the most common cause of nonviral encephalitis. It presents fulminantly with progressive psychosis, seizures, and autonomic dysfunction, leading to death if untreated. However, rapid recognition and treatment can lead to survival and a return to baseline levels of functioning in many patients. While initially associated with ovarian teratomas, it is now associated with other tumors and can reflect a postviral event. The antibodies to the NMDAR made in this syndrome are pathogenic and are directed at the extracellular domain of the GluN1 subunit. Such antibodies lead to internalization of NMDARs in model systems, leading to a physiological state characterized by NMDAR hypofunction. Analogous disorders, characterized by antibodies to other synaptic receptors, present with neurological and psychiatric dysfunction and also appear to reflect antibody-induced internalization of receptors. However, this simple pathophysiology may be too simplistic to reflect the complexity of events in anti-NMDAR encephalitis. Future scientific investigations may allow a more complete understanding of this disorder and improve treatment of anti-NMDAR encephalitis.

Complexity and wide range of neuromyelitis optica spectrum disorders: more than typical manifestations

Neuromyelitis optica (NMO), considered to be mediated by autoantibodies, often cause severely disabling disorders of the central nervous system, and predominantly cause optic nerve damage and longitudinally extensive transverse myelitis. Remarkable progress has been made in deciphering NMO pathogenesis during the past decade. In 2015, the International Panel for NMO Diagnosis proposed the unifying term "NMO spectrum disorders" (NMOSD) and the updated NMOSD criteria reflects a wide range of disease and maintains reasonable specificity. Moreover, cumulative findings have indicated that NMOSD are frequently associated with multiple autoimmune diseases, thereby presenting complex clinical symptoms that make this disease more difficult to recognize. Notably, most neurologists do not heed these symptoms or comorbid conditions in patients with NMOSD. Whereas previous reviews have focused on pathogenesis, treatment, and prognosis in NMOSD, we summarize the present knowledge with particular emphasis on atypical manifestations and autoimmune comorbidities in patients with NMOSD. Furthermore, we emphasized the identification of these atypical characteristics to enable a broader and better understanding of NMOSD, and improve early accurate diagnosis and therapeutic decision making.