1
|
Zhang W, Cao W, Tao W, Wang Y, Tangzhu C, Shen Q, Shi X. Anti-NMDAR encephalitis in a child with long impaired consciousness and persistent antibodies: a case report and mini review. Front Immunol 2024; 15:1402523. [PMID: 38863715 PMCID: PMC11165090 DOI: 10.3389/fimmu.2024.1402523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/14/2024] [Indexed: 06/13/2024] Open
Abstract
We described a challenging case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in a young girl. Despite enduring months of reduced consciousness with ongoing antibody presence, she ultimately exhibited remarkable improvement within a 5-year follow-up period. Additionally, we conducted a concise review of relevant literature on anti-NMDAR encephalitis, with a specific focus on anti-NMDAR antibodies. Our findings enhance the clinical comprehension of anti-NMDAR encephalitis and offer valuable insights to clinicians for its management.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Xulai Shi
- Department of Pediatric Neurology, The Second Affiliated Hospital & Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| |
Collapse
|
2
|
Hommady R, Alsohibani A, Alayed R, Alshehri A, AbuMelha A, Aljomah L, Hundallah K, Almuqbil M, Altuwaijri W, Alrumayyan A, Alrifai MT, Baarmah DM. Effectiveness of intra-thecal methotrexate in refractory Anti-N-methyl-d-aspartate receptor encephalitis. BMC Neurol 2023; 23:261. [PMID: 37420168 DOI: 10.1186/s12883-023-03301-8] [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: 05/17/2023] [Accepted: 06/22/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Anti-N-methyl-d-aspartate "anti-NMDA" receptor encephalitis is one of the most common autoimmune encephalitis for which first- and second-line therapies have been recommended following international consensus. However, some refractory cases do not respond to the first- and second-line therapy and require further immune-modulatory therapies such as intra-thecal methotrexate. In this study, we reviewed six confirmed cases of refractory anti-NMDA receptor encephalitis from two tertiary centers in Saudi Arabia that required escalation of treatment and received a six-month course of intra-thecal methotrexate. The aim of this study was to evaluate the effectiveness of intra-thecal methotrexate as immunomodulatory therapy for refractory anti-NMDA receptor encephalitis. METHODS We retrospectively evaluated six confirmed cases of refractory anti-NMDA receptor encephalitis who did not improve after first- and second-line therapy and received monthly intra-thecal methotrexate treatment course for six consecutive months. We reviewed patient demography, underlying etiologies, and compared their modified Rankin score prior to receiving intra-thecal methotrexate and six months after completing the treatment. RESULTS Three of the six patients showed a marked response to intra-thecal methotrexate with a modified Rankin scale of 0-1 at 6-month follow-up. None of the patients experienced any side effects during or after intra-thecal methotrexate treatment, and no flareups were observed. CONCLUSION Intra-thecal methotrexate may be a potentially effective and relatively safe escalation option for immunomodulatory therapy of refractory anti-NMDA receptor encephalitis. Future studies on intra-thecal methotrexate -specific treatment regimens may further support its utility, efficacy, and safety in treating refractory anti-NMDA receptor encephalitis.
Collapse
Affiliation(s)
- Raid Hommady
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Abdullah Alsohibani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Ruba Alayed
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Abdulaziz Alshehri
- Department of Pediatric Neurology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahlam AbuMelha
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Lama Aljomah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Khalid Hundallah
- Department of Pediatric Neurology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed Almuqbil
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Waleed Altuwaijri
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Ahmad Alrumayyan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Muhammad Talal Alrifai
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Division of Pediatric Neurology, Department of Pediatrics, King Abdullah Specialist Children's Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- Ministry of National Guard, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Duaa Mohammed Baarmah
- Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
| |
Collapse
|
3
|
李 宇, 蒋 莉. Recent research on immunotherapy for anti-N-methyl-D-aspartate receptor encephalitis. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:948-953. [PMID: 36036136 PMCID: PMC9425858 DOI: 10.7499/j.issn.1008-8830.2204021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/03/2022] [Indexed: 01/24/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a central nervous system disease characterized by neurological and psychiatric symptoms. Immunotherapy is the basic treatment for this disease, including first- and second-line therapies for the acute stage and the long-course therapy for the chronic stage. Anti-NMDAR encephalitis often has a good prognosis, but some patients may still have neurological dysfunction due to poor response to current immunotherapy. In addition, the adverse reactions and economic burden of drugs are practical problems in clinical practice. To solve the above problems, continuous improvements have been made in immunotherapy regimens in terms of dose, route of administration, and course of treatment, and some new immunotherapy drugs have emerged. This article reviews the recent research on immunotherapy for anti-NMDAR encephalitis.
Collapse
|
4
|
Wright MA, Trandafir CC, Nelson GR, Hersh AO, Inman CJ, Zielinski BA. Diagnosis and Management of Suspected Pediatric Autoimmune Encephalitis: A Comprehensive, Multidisciplinary Approach and Review of Literature. J Child Neurol 2022; 37:303-313. [PMID: 34927485 DOI: 10.1177/08830738211064673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Autoimmune encephalitis is an increasingly recognized entity in children. When treated promptly, favorable outcomes are seen in a majority of pediatric patients. However, recognition of autoimmune encephalitis in young patients is challenging. Once autoimmune encephalitis is suspected, additional difficulties exist regarding timing of treatment initiation and duration of treatment, as evidence to guide management of these patients is emerging. Here, we review available literature regarding pediatric autoimmune encephalitis and present our institution's comprehensive approach to the evaluation and management of the disease. These guidelines were developed through an iterative process involving both pediatric neurologists and rheumatologists.
Collapse
Affiliation(s)
- Melissa A Wright
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Cristina C Trandafir
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Gary R Nelson
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Aimee O Hersh
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - C J Inman
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Brandon A Zielinski
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Department of Neurology, 14434University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
5
|
Teng Y, Li T, Yang Z, Su M, Ni J, Wei M, Shi J, Tian J. Clinical Features and Therapeutic Effects of Anti-leucine-rich Glioma Inactivated 1 Encephalitis: A Systematic Review. Front Neurol 2022; 12:791014. [PMID: 35095736 PMCID: PMC8791026 DOI: 10.3389/fneur.2021.791014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/02/2021] [Indexed: 01/17/2023] Open
Abstract
Background: Clinical presentations and treatment programs about anti-leucine-rich glioma inactivated 1 (LGI1) encephalitis still remain incompletely understood. Objective: This study analyzed the clinical features and therapeutic effects of anti-LGI1 encephalitis. Methods: PubMed, EMBASE, and the Cochrane Library were searched to identify published English and Chinese articles until April 2021. Data were extracted, analyzed, and recorded in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 80 publications detailing 485 subjects matched our inclusion criteria. Short-term memory loss (75.22%), faciobrachial dystonic seizures (FBDS) (52.53%), other seizures excluding FBDS (68.48%), psychiatric symptoms (57.67%), and sleep disturbances (34.30%) were the most frequently described symptoms in anti-LGI1 encephalitis. Hyponatremia (54.90%) was the most common hematologic examination change. The risk of incidence rate of malignant tumors was higher than in healthy people. The positive rate of anti-LGI1 in serum (99.79%) was higher than CSF (77.38%). Steroids (93.02%), IVIG (87.50%), and combined use (96.67%) all had a high remission rate in the initial visit. A total of 35 of 215 cases relapsed, of which 6/35 (17.14%) did not use first-line treatment, and 21 (60.00%) did not maintain long-term treatment. Plasma exchange (PE) could be combined in severe patients, immunosuppressant could be used for refractory patients or for recurrence and using an anti-epileptic drug to control seizures may benefit cognition. Conclusions: Short-term memory loss, FBDS, psychiatric symptoms, and hyponatremia were key features in identifying anti-LGI1 encephalitis. Serum and CSF antibody tests should be considered in diagnosis criteria. Steroids with IVIG should be recommended, PE was combined for use in severe patients, immunosuppressant therapy might improve outcomes if recurrence or progression occurred, and control seizures might benefit cognition. The useful ways to reduce relapse rate were early identification, clear diagnosis, rapid treatment, and maintaining long-term treatment. The follow-up advice was suggested according to the research of paraneoplastic syndrome, and concern about tumors was vital as well.
Collapse
Affiliation(s)
- Yuou Teng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ting Li
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Zhizhong Yang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mingwan Su
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingnian Ni
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mingqing Wei
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Shi
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinzhou Tian
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
6
|
Radosevic M, Planagumà J, Mannara F, Mellado A, Aguilar E, Sabater L, Landa J, García-Serra A, Maudes E, Gasull X, Lewis M, Dalmau J. Allosteric Modulation of NMDARs Reverses Patients' Autoantibody Effects in Mice. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/1/e1122. [PMID: 34903638 PMCID: PMC8669659 DOI: 10.1212/nxi.0000000000001122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
Abstract
Background and Objectives To demonstrate that an analog (SGE-301) of a brain-derived cholesterol metabolite, 24(S)-hydroxycholesterol, which is a selective positive allosteric modulator (PAM) of NMDA receptors (NMDARs), is able to reverse the memory and synaptic alterations caused by CSF from patients with anti-NMDAR encephalitis in an animal model of passive transfer of antibodies. Methods Four groups of mice received (days 1–14) patients' or controls' CSF via osmotic pumps connected to the cerebroventricular system and from day 11 were treated with daily subcutaneous injections of SGE-301 or vehicle (no drug). Visuospatial memory, locomotor activity (LA), synaptic NMDAR cluster density, hippocampal long-term potentiation (LTP), and paired-pulse facilitation (PPF) were assessed on days 10, 13, 18, and 26 using reported techniques. Results On day 10, mice infused with patients' CSF, but not controls' CSF, presented a significant visuospatial memory deficit, reduction of NMDAR clusters, and impairment of LTP, whereas LA and PPF were unaffected. These alterations persisted until day 18, the time of maximal deficits in this model. In contrast, mice that received patients' CSF but from day 11 were treated with SGE-301 showed memory recovery (day 13), and on day 18, all paradigms (memory, NMDAR clusters, and LTP) had reversed to values similar to those of controls. On day 26, no differences were observed among experimental groups. Discussion An oxysterol biology-based PAM of NMDARs is able to reverse the synaptic and memory deficits caused by CSF from patients with anti-NMDAR encephalitis. These findings suggest a novel adjuvant treatment approach that deserves future clinical evaluation.
Collapse
|
7
|
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.
Collapse
|
8
|
Kao YC, Lin MI, Weng WC, Lee WT. Neuropsychiatric Disorders Due to Limbic Encephalitis: Immunologic Aspect. Int J Mol Sci 2020; 22:ijms22010389. [PMID: 33396564 PMCID: PMC7795533 DOI: 10.3390/ijms22010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022] Open
Abstract
Limbic encephalitis (LE) is a rare cause of encephalitis presenting as an acute and subacute onset of neuropsychiatric manifestations, particularly with memory deficits and confusion as core features, along with seizure occurrence, movement disorders, or autonomic dysfunctions. LE is caused by neuronal antibodies targeting the cellular surface, synaptic, and intracellular antigens, which alter the synaptic transmission, especially in the limbic area. Immunologic mechanisms involve antibodies, complements, or T-cell-mediated immune responses in different degree according to different autoantibodies. Sensitive cerebrospinal fluid markers of LE are unavailable, and radiographic findings may not reveal a typical mesiotemporal involvement at neurologic presentations; therefore, a high clinical index of suspicions is pivotal, and a neuronal antibody testing is necessary to make early diagnosis. Some patients have concomitant tumors, causing paraneoplastic LE; therefore, tumor survey and treatment are required in addition to immunotherapy. In this study, a review on the molecular and immunologic aspects of LE was conducted to gain awareness of its peculiarity, which we found quite different from our knowledge on traditional psychiatric illness.
Collapse
Affiliation(s)
- Yu-Chia Kao
- Department of Pediatrics, E-Da Hospital, Kaohsiung 82445, Taiwan;
| | - Ming-I Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 11101, Taiwan;
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei 100226, Taiwan;
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71545); Fax: +886-2-23147450
| |
Collapse
|
9
|
Cao XS, Kessi M, Ji TY, Jiang YW, Yin F, Peng J. A survey on pediatric anti-N-methyl-D-aspartate-receptor encephalitis treatment strategies in China. Chin Med J (Engl) 2020; 134:1498-1499. [PMID: 33323814 PMCID: PMC8213264 DOI: 10.1097/cm9.0000000000001308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Xiao-Shuang Cao
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410005, China
| | - Miriam Kessi
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, Hunan 410005, China
| | - Tao-Yun Ji
- Department of Pediatrics, Peking University First Hospital, Beijing100034, China
- Division of Pediatric Neurology, Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Yu-Wu Jiang
- Department of Pediatrics, Peking University First Hospital, Beijing100034, China
- Division of Pediatric Neurology, Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410005, China
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410005, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, Hunan 410005, China
| |
Collapse
|
10
|
Hao XS, Wang JT, Chen C, Hao YP, Liang JM, Liu SY. Effectiveness of Mycophenolate Mofetil in the Treatment of Pediatric Anti-NMDAR Encephalitis: A Retrospective Analysis of 6 Cases. Front Neurol 2020; 11:584446. [PMID: 33240207 PMCID: PMC7680875 DOI: 10.3389/fneur.2020.584446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the effectiveness and safety of mycophenolate mofetil (MMF) as a second-line medication in the treatment of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, the most common and severe autoimmune encephalitis. Methods: The clinical data of six children with anti-NMDAR encephalitis admitted to the First Hospital of Jilin University were retrospectively analyzed, and the effectiveness and safety of MMF were evaluated. Results: Six children with anti-NMDAR encephalitis were treated with MMF in the 2nd or 3rd treatment disease event (3 cases vs. 3 cases). MMF initiation was mean 19.2 months (range 6-39 months) after disease onset at a mean dose of 25.6 mg/kg (range 19.6-28.4 mg/kg) for 14 months (range 6-26 months). Only two patients had transient mild diarrhea within 2 weeks of MMF application. During follow-up, one patient relapsed whilst on MMF, one patient discontinued MMF, and 4 cases were still on MMF. Conclusion: The use of MMF in anti-NMDAR encephalitis may be effective and safe. MMF can be used as one of the relapse prevention options in patients who already have relapsed or possibly even after the first event. Delayed use may be the main reason for MMF failure.
Collapse
Affiliation(s)
- Xiao-Sheng Hao
- The First Hospital of Jilin University, Changchun, China
| | - Jiang-Tao Wang
- The First Hospital of Jilin University, Changchun, China
| | - Chen Chen
- The First Hospital of Jilin University, Changchun, China
| | - Yun-Peng Hao
- The First Hospital of Jilin University, Changchun, China
| | - Jian-Min Liang
- The First Hospital of Jilin University, Changchun, China
| | - Song-Yan Liu
- The China-Japan Union Hospital, Changchun, China
| |
Collapse
|
11
|
|
12
|
Cordani R, Micalizzi C, Giacomini T, Gastaldi M, Franciotta D, Fioredda F, Buratti S, Morana G, Pirlo D, Renna S, Castagnola E, Risso M, Lanteri P, Vari MS, Mancardi MM. Bortezomib-Responsive Refractory Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Pediatr Neurol 2020; 103:61-64. [PMID: 31759783 DOI: 10.1016/j.pediatrneurol.2019.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/23/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor encephalitis is a central nervous system inflammatory autoimmune disease affecting adults and children. The use of first- and second-line immunotherapies is supported. Recent reports suggest the efficacy of bortezomib in severe anti-N-methyl-d-aspartate encephalitis in adult patients not responsive to second-line treatment; there are no data about pediatric patients. PATIENT DESCRIPTION We describe an eight-year-old child with anti-N-methyl-d-aspartate encephalitis not responsive to first- and second-line treatments who experienced marked clinical improvement after bortezomib administration. DISCUSSION Bortezomib is a selective and reversible inhibitor of the 26S proteasome, which is used to treat oncologic and rare autoimmune disorders in pediatric patients. As observed in adult patients, bortezomib administration induced anti-N-methyl-d-aspartate antibody titer decline and clinical improvement with an acceptable risk profile. CONCLUSION This is the first report of the use of bortezomib in children with anti-N-methyl-d-aspartate encephalitis; it could be a useful therapeutic option in children with refractory anti-N-methyl-d-aspartate encephalitis.
Collapse
Affiliation(s)
- Ramona Cordani
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | | | - Thea Giacomini
- Unit of Child Neuropsichiatry, Department of Neuroscience, Ophthalmology Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, IRCCS Giannina Gaslini, Genova, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Giovanni Morana
- Unit of Neuroradiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Daniela Pirlo
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Salvatore Renna
- Department of Emergency, IRCCS Giannina Gaslini, Genova, Italy
| | - Elio Castagnola
- Unit of Infectious Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Marco Risso
- Unit of Immunology and Transfusional Medicine, IRCCS Giannina Gaslini, Genova, Italy
| | - Paola Lanteri
- Unit of Neurophysiology, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Stella Vari
- Unit of Pediatric Neurology and Neurogenerative Diseases, IRCCS Giannina Gaslini, Genova, Italy
| | - Maria Margherita Mancardi
- Unit of Child Neuropsichiatry, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCCS Giannina Gaslini, Genova, Italy.
| |
Collapse
|
13
|
Buechner S, Florio I, Sixt GJ, Teatini F. A critical reflection on our first patient presenting with Anti-Nmethyl- D-aspartate receptor encephalitis. Neurol Int 2019; 11:8253. [PMID: 31579162 PMCID: PMC6763749 DOI: 10.4081/ni.2019.8253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023] Open
Abstract
One of the best characterized autoimmune encephalitis is the Anti-Nmethyl- D-aspartate receptor (NMDAR) encephalitis, which may occur in the presence of cancer. First- and second-line immunotherapy and oncological investigations are suggested. We present here a case of an 18-year-old female who was our first patient suffering from Anti- NMDAR encephalitis more than 9 years ago. She was satisfactorily treated with intravenous immunoglobulins and high dose steroid therapy. After more than one year the patient had a relapse. First-line immunotherapy was repeated; however, a complete recovery was achieved only after plasmapheresis. Afterwards, she continued maintenance immunotherapy with steroids for two years and with Azathioprine for about five years associated to regular oncological assessment. In the last years our therapeutical approach of Anti-NMDARencephalitis has significantly changed. Nevertheless, established treatment guidelines are still missing and the role of long-term maintenance immunotherapy is largely unexplored. In addition, oncological revaluation might be indicated in selected patients.
Collapse
Affiliation(s)
- Susanne Buechner
- Department of Neurology/Stroke Unit, General Hospital of Bolzano, Italy
| | - Igor Florio
- Department of Neurology/Stroke Unit, General Hospital of Bolzano, Italy
| | - Gabriele J Sixt
- Department of Neurology/Stroke Unit, General Hospital of Bolzano, Italy
| | - Francesco Teatini
- Department of Neurology/Stroke Unit, General Hospital of Bolzano, Italy
| |
Collapse
|
14
|
Nosadini M, Granata T, Matricardi S, Freri E, Ragona F, Papetti L, Suppiej A, Valeriani M, Sartori S. Relapse risk factors in anti-N-methyl-D-aspartate receptor encephalitis. Dev Med Child Neurol 2019; 61:1101-1107. [PMID: 31175679 DOI: 10.1111/dmcn.14267] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2019] [Indexed: 01/16/2023]
Abstract
AIM To identify factors that may predict and affect the risk of relapse in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHOD This was a retrospective study of an Italian cohort of patients with paediatric (≤18y) onset anti-NMDAR encephalitis. RESULTS Of the 62 children included (39 females; median age at onset 9y 10mo, range 1y 2mo-18y; onset between 2005 and 2018), 21 per cent relapsed (median two total events per relapsing patient, range 2-4). Time to first relapse was median 31.5 months (range 7-89mo). Severity at first relapse was lower than onset (median modified Rankin Scale [mRS] 3, range 2-4, vs median mRS 5, range 3-5; admission to intensive care unit: 0/10 vs 3/10). At the survival analysis, the risk of relapsing was significantly lower in patients who received three or more different immune therapies at first disease event (hazard ratio 0.208, 95% confidence interval 0.046-0.941; p=0.042). Neurological outcome at follow-up did not differ significantly between patients with relapsing and monophasic disease (mRS 0-1 in 39/49 vs 12/13; p=0.431), although follow-up duration was significantly longer in relapsing (median 84mo, range 14-137mo) than in monophasic patients (median 32mo, range 4-108mo; p=0.002). INTERPRETATION Relapses may occur in about one-fifth of children with anti-NMDAR encephalitis, are generally milder than at onset, and may span over a long period, although they do not seem to be associated with severity in the acute phase or with outcome at follow-up. Aggressive immune therapy at onset may reduce risk of relapse. WHAT THIS PAPER ADDS Relapses of anti-N-methyl-D-aspartate receptor encephalitis may span over a long period. Relapses were not associated with severity in the acute phase or outcome at follow-up. Aggressive immune therapy at onset appears to decrease risk of relapse.
Collapse
Affiliation(s)
- Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute 'Città della Speranza', Padua, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Foundation IRCCS Neurological Institute 'C. Besta', Milan, Italy
| | - Laura Papetti
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Agnese Suppiej
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Massimiliano Valeriani
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute 'Città della Speranza', Padua, Italy
| | | |
Collapse
|
15
|
Dalmau J, Armangué T, Planagumà J, Radosevic M, Mannara F, Leypoldt F, Geis C, Lancaster E, Titulaer MJ, Rosenfeld MR, Graus F. An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol 2019; 18:1045-1057. [PMID: 31326280 DOI: 10.1016/s1474-4422(19)30244-3] [Citation(s) in RCA: 428] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/18/2022]
Abstract
The identification of anti-NMDA receptor (NMDAR) encephalitis about 12 years ago made it possible to recognise that some patients with rapidly progressive psychiatric symptoms or cognitive impairment, seizures, abnormal movements, or coma of unknown cause, had an autoimmune disease. In this disease, autoantibodies serve as a diagnostic marker and alter NMDAR-related synaptic transmission. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. The severity of symptoms often requires intensive care. Other than clinical assessment, no specific prognostic biomarkers exist. The disease is more prevalent in women (with a female to male ratio of around 8:2) and about 37% of patients are younger than 18 years at presentation of the disease. Tumours, usually ovarian teratoma, and herpes simplex encephalitis are known triggers of NMDAR autoimmunity. About 80% of patients improve with immunotherapy and, if needed, tumour removal, but the recovery is slow. Animal models have started to reveal the complexity of the underlying pathogenic mechanisms and will lead to novel treatments beyond immunotherapy. Future studies should aim at identifying prognostic biomarkers and treatments that accelerate recovery.
Collapse
Affiliation(s)
- Josep Dalmau
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Centro de Investigación Biomédica en Red para Enfermedades Raras, Madrid, Spain; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain.
| | - Thais Armangué
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Department of Neurology, Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Jesús Planagumà
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marija Radosevic
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Francesco Mannara
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany; Department of Neurology, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Christian Geis
- Translational Neuroimmunology, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Eric Lancaster
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Myrna R Rosenfeld
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Francesc Graus
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| |
Collapse
|
16
|
Management of antibody-mediated autoimmune encephalitis in adults and children: literature review and consensus-based practical recommendations. Neurol Sci 2019; 40:2017-2030. [PMID: 31161339 DOI: 10.1007/s10072-019-03930-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 05/09/2019] [Indexed: 12/24/2022]
Abstract
Autoimmune encephalitis associated with antibodies against neuronal surface targets (NSAE) are rare but still underrecognized conditions that affect adult and pediatric patients. Clinical guidelines have recently been published with the aim of providing diagnostic clues regardless of antibody status. These syndromes are potentially treatable but the choice of treatment and its timing, as well as differential diagnoses, long-term management, and clinical and paraclinical follow-up, remain major challenges. In the absence of evidence-based guidelines, management of these conditions is commonly based on single-center expertise.Taking into account different published expert recommendations in addition to the multicenter experience of the Italian Working Group on Autoimmune Encephalitis, both widely accepted and critical aspects of diagnosis, management and particularly of immunotherapy for NSAE have been reviewed and are discussed.Finally, we provide consensus-based practical advice for managing hospitalization and follow-up of patients with NSAE.
Collapse
|