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Vaišvilas M, Ciano-Petersen NL, Macarena Villagrán-García MD, Muñiz-Castrillo S, Vogrig A, Honnorat J. Paraneoplastic encephalitis: clinically based approach on diagnosis and management. Postgrad Med J 2023; 99:669-678. [PMID: 37389581 DOI: 10.1136/postgradmedj-2022-141766] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
Paraneoplastic neurological syndromes (PNSs) comprise a subset of immune-mediated nervous system diseases triggered by an underlying malignancy. Each syndrome usually shows a distinct clinical presentation and outcome according to the associated neural antibodies. PNSs generally have a subacute onset with rapid progression and severe neurological disability. However, some patients may have hyperacute onset or even show chronic progression mimicking neurodegenerative diseases. Updated diagnostic criteria for PNS have been recently established in order to increase diagnostic specificity and to encourage standardisation of research initiatives related to PNS. Treatment for PNS includes oncological therapy and immunomodulation to halt neurological deterioration although current treatment options are seldom effective in reversing disability. Nevertheless, growing knowledge and better understanding of PNS pathogenesis promise better recognition, earlier diagnosis and novel treatment strategies. Considering that PNSs provide a model of effective anticancer immunity, the impact of these studies will extend far beyond the field of neurology.
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Affiliation(s)
- Mantas Vaišvilas
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Nicolás Lundahl Ciano-Petersen
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - M D Macarena Villagrán-García
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Sergio Muñiz-Castrillo
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Alberto Vogrig
- Department of Neuro-oncology Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
| | - Jérôme Honnorat
- Department of Neuro-oncology, Université Claude Bernard Lyon 1 Villeurbanne, Lyon, France
- Department of Neuro-oncology, Hospices Civils de Lyon, Bron, France
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2
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Huang P, Xu M. Four kinds of antibody positive paraneoplastic limbic encephalitis: A rare case report. World J Clin Cases 2023; 11:1586-1592. [PMID: 36926412 PMCID: PMC10012000 DOI: 10.12998/wjcc.v11.i7.1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/14/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND It is not uncommon to develop autoimmune encephalitis and paraneoplastic neurological syndromes (PNS). 4 kinds of antibody-positive autoimmune paraneoplastic limbic encephalitis (PLE) have not been reported.
CASE SUMMARY PNS are distant effects of cancer on the nervous system, rather than syndromes in which cancer directly invades and metastasizes to the nerves and/or muscle tissues. If the limbic lobe system of the brain is involved, this will result in PLE. The detection of patients with PNS is challenging since tumors that cause paraneoplastic neurologic disorders are often asymptomatic, obscure, and thus easily misdiagnosed or missed. Currently, single- or double-antibody-positive paraneoplastic marginal encephalitis has been reported. However, no cases of three or more-antibody-positive cases have been reported. Here, we report a case of PLE that is anti-collapsing response-mediator protein-5, anti-neuronal nuclear antibody-type 1, anti-aminobutyric acid B receptor, and anti-glutamate deglutase positive, and address relevant literature to improve our understanding of the disease.
CONCLUSION This article reports on the management of a case of PLE with four positive antibodies, a review of the literature, in order to raise awareness among clinicians.
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Affiliation(s)
- Pan Huang
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan Province, China
| | - Min Xu
- Department of Neurology, The Second People’s Hospital of Deyang City, Deyang 618000, Sichuan Province, China
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3
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Picard L, Mailles A, Fillâtre P, Tattevin P, Stahl JP. Encephalitis in travellers: A prospective multicentre study. J Travel Med 2022; 30:6869133. [PMID: 36461934 DOI: 10.1093/jtm/taac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/12/2022] [Accepted: 11/29/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND As the epidemiology of encephalitis varies from one country to another, international travel may be an important clue for the diagnostic workout of this puzzling disease. METHODS We performed an ancillary study using the ENCEIF prospective cohort conducted in 62 clinical sites in France from 2016 to 2019. All cases of encephalitis in adults that fulfilled a case definition derived from the International Encephalitis Consortium were included. Travellers were defined as patients who spent at least one night in a foreign country within the last six months. RESULTS Of the 494 encephalitis patients enrolled, 69 (14%) were travellers. As compared to non-travellers, they were younger (median age, 48 years [interquartile range, 36-69] vs. 66 [49-76], P < 0.001), less likely to be immunocompromised: 2/69 (3%) vs 56/425 (13%), P = 0.02, and reported more arthralgia: 7/69 (10%) vs. 11/425 (3%), P = 0.007. The risk of poor outcome at hospital discharge (Glasgow outcome scale ≤ 3), was similar for travellers and for non-travellers after adjustment (aOR 0.80 [0.36-1.80], P = 0.594). Arboviruses were the main causes of encephalitis in travellers: 15/69 (22%) vs. 20/425 (5%) in non-travellers, P < 0.001, and Herpes simplex virus (HSV) was the second (9/69, 13%). Of note, in 19% (13/69) of cases, the risk of encephalitis in travellers may have been decreased with a vaccine. CONCLUSION The two primary causes of encephalitis in travellers are arboviruses, and HSV. Empirical treatment of encephalitis in travellers must include aciclovir. Pre-travel advice and vaccination may decrease the risk of encephalitis in travellers.
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Affiliation(s)
- Léa Picard
- Université Rennes 1, Service des Maladies Infectieuses et Réanimation Médicale, Centre Hospitalo-Universitaire, Rennes, France
| | - Alexandra Mailles
- Santé Publique France, Direction des Maladies Infectieuses, Saint-Maurice, France.,European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infectious diseases of the Brain (ESGIB), Basel, Switzerland
| | - Pierre Fillâtre
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infectious diseases of the Brain (ESGIB), Basel, Switzerland.,Service de Réanimation Polyvalente, Centre Hospitalier, Saint-Brieuc, France
| | - Pierre Tattevin
- Université Rennes 1, Service des Maladies Infectieuses et Réanimation Médicale, Centre Hospitalo-Universitaire, Rennes, France.,European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infectious diseases of the Brain (ESGIB), Basel, Switzerland
| | - Jean-Paul Stahl
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infectious diseases of the Brain (ESGIB), Basel, Switzerland.,Université Grenoble Alpes, Maladies Infectieuses, France
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Li W, Jia D, Tong L, Lun Z, Li H. Anti-N-methyl-D-aspartate receptor encephalitis induced by bilateral ovarian teratomas with distinct histopathologic types: A case report and brief literature review. Medicine (Baltimore) 2019; 98:e18148. [PMID: 31770255 PMCID: PMC6890280 DOI: 10.1097/md.0000000000018148] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder that is most frequently induced by ovarian teratoma in young females. The condition can be controlled and reversed via ovarian tumor resection and immunotherapy. However, anti-NMDAR encephalitis induced by bilateral ovarian teratomas with distinct histopathologic types is rarely reported in the literature. PATIENT CONCERNS A 23-year-old woman presented with seizures. DIAGNOSES The diagnosis was anti-NMDAR encephalitis associated with ovarian teratomas based on positive anti-NMDAR antibody tests in both the cerebrospinal fluid and serum, and the detection of bilateral ovarian lesions on pelvic computed tomography. The postoperative histopathologic examination confirmed that the left lesion was an immature teratoma, and the right lesion was a mature teratoma. INTERVENTIONS We performed surgical resection of the ovarian teratomas and administered immunotherapy for the control of anti-NMDAR encephalitis. Chemotherapy was administered for the immature teratoma. OUTCOMES The patient recovered without any postoperative complications. She has been confirmed to be in complete clinical remission, and has not had a recurrence during 18 months of follow-up. LESSONS Anti-NMDAR encephalitis induced by bilateral ovarian teratomas of differing histopathologic types (1 immature and 1 mature) is rare. Early diagnosis and treatment with tumor resection, immunotherapy, and chemotherapy are critical for a good prognosis.
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Affiliation(s)
| | | | | | | | - Hailiang Li
- Department of Outpatient, The First Hospital of Jilin University, Changchun, Jilin, China
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5
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Blinder T, Lewerenz J. Cerebrospinal Fluid Findings in Patients With Autoimmune Encephalitis-A Systematic Analysis. Front Neurol 2019; 10:804. [PMID: 31404257 PMCID: PMC6670288 DOI: 10.3389/fneur.2019.00804] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/11/2019] [Indexed: 01/15/2023] Open
Abstract
Autoimmune encephalitides (AIE) comprise a group of inflammatory diseases of the central nervous system (CNS), which can be further characterized by the presence of different antineuronal antibodies. Recently, a clinical approach for diagnostic criteria for the suspected diagnosis of AIE as well as definitive AIE were proposed. These are intended to guide physicians when to order the antineuronal antibody testing and/or facilitate early diagnosis even prior to the availability of the specific disease-confirming test results to facilitate prompt treatment. These diagnostic criteria also include the results of basic cerebrospinal fluid (CSF) analysis. However, the different antibody-defined AIE subtypes might be highly distinct with regard to their immune pathophysiology, e.g., the pre-dominance of specific IgG subclasses, IgG1, or IgG4, or frequency of paraneoplastic compared to idiopathic origin. Thus, it is conceivable that the results of basic CSF analysis might also be very different. However, this has not been explored systematically. Here, we systematically reviewed the literature about the 10 most important AIE subtypes, AIE with antibodies against NMDA, AMPA, glycine, GABAA, and GABAB receptors as well as DPPX, CASPR2, LGI1, IgLON5, or glutamate decarboxylase (GAD), with respect to the reported basic CSF findings comprising CSF leukocyte count, total protein, and the presence of oligoclonal bands (OCB) restricted to the CSF as a sensitive measure for intrathecal IgG synthesis. Our results indicate that these basic CSF findings are profoundly different among the 10 different AIE subtypes. Whereas, AIEs with antibodies against NMDA, GABAB, and AMPA receptors as well as DPPX show rather frequent inflammatory CSF changes, in AIEs with either CASPR2, LGI1, GABAA, or glycine receptor antibodies CSF findings were mostly normal. Two subtypes, AIEs defined by either GAD, or IgLON5 antibodies, did not fit into this general pattern. In AIE with GAD antibodies, positive OCBs in the absence of other changes were typical, while the CSF in IgLON5 antibody-positive AIE was characterized by elevated protein.
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Affiliation(s)
| | - Jan Lewerenz
- Department of Neurology, Ulm University, Ulm, Germany
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6
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Cai X, Zhou H, Xie Y, Yu D, Wang Z, Ren H. Anti-N-methyl-D-aspartate receptor encephalitis associated with acute Toxoplasma gondii infection: A case report. Medicine (Baltimore) 2018; 97:e9924. [PMID: 29443773 PMCID: PMC5839864 DOI: 10.1097/md.0000000000009924] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis has been recognized as the most frequent autoimmune encephalitis in children. Several infectious agents have been implicated in anti-NMDA encephalitis. PATIENT CONCERNS A previously healthy immunocompetent 9-year-old girl first presented with seizures, headaches and vomiting. Cerebrospinal fluid and brain magnetic resonance imaging were normal. After one week onset, the patient gradually developed unexplained personality and behavior changes, accompanied by fever and seizures again. Repeated CSF analysis revealed a slightly lymphocytic predominant pleocytosis and positive anti-NMDAR antibody. A variety of pathogenic examinations were negative, except for positive toxoplasma IgM and IgG. DIAGNOSES The patient was diagnoses for anti-NMDA encephalitis associated with acute acquired toxoplasma gondii infection. INTERVENTIONS The patient received 10 days azithromycin for treatment of acquired toxoplasma infection. The parents refuse immunotherapy because substantial recovery from clinical symptoms. OUTCOMES The patient was substantially recovered with residual mild agitation after therapy for acquired toxoplasma gondii infection. Two months later, the patient was completely devoid of symptoms, and the levels of serum IgM and IgG of toxoplasma gondii were decreased. LESSONS Acquired toxoplasma gondii infection may trigger anti-NMDAR encephalitis in children, which has not been reported previously. Clinicians should assess the possibility of toxoplasma gondii infection when evaluating a patient with anti-NMDA encephalitis.
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Affiliation(s)
- Xiaotang Cai
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan
| | - Hui Zhou
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan
| | - Yongmei Xie
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan
| | - Dan Yu
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan
| | - Zhiling Wang
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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8
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Encéphalites auto-immunes et encéphalites paranéoplasiques : ce que le réanimateur doit savoir. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chefdeville A, Honnorat J, Hampe CS, Desestret V. Neuronal central nervous system syndromes probably mediated by autoantibodies. Eur J Neurosci 2016; 43:1535-52. [PMID: 26918657 DOI: 10.1111/ejn.13212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/09/2016] [Accepted: 02/15/2016] [Indexed: 01/17/2023]
Abstract
In the last few years, a rapidly growing number of autoantibodies targeting neuronal cell-surface antigens have been identified in patients presenting with neurological symptoms. Targeted antigens include ionotropic receptors such as N-methyl-d-aspartate receptor or the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, metabotropic receptors such as mGluR1 and mGluR5, and other synaptic proteins, some of them belonging to the voltage-gated potassium channel complex. Importantly, the cell-surface location of these antigens makes them vulnerable to direct antibody-mediated modulation. Some of these autoantibodies, generally targeting ionotropic channels or their partner proteins, define clinical syndromes resembling models of pharmacological or genetic disruption of the corresponding antigen, suggesting a direct pathogenic role of the associated autoantibodies. Moreover, the associated neurological symptoms are usually immunotherapy-responsive, further arguing for a pathogenic effect of the antibodies. Some studies have shown that some patients' antibodies may have structural and functional in vitro effects on the targeted antigens. Definite proof of the pathogenicity of these autoantibodies has been obtained for just a few through passive transfer experiments in animal models. In this review we present existing and converging evidence suggesting a pathogenic role of some autoantibodies directed against neuronal cell-surface antigens observed in patients with central nervous system disorders. We describe the main clinical symptoms characterizing the patients and discuss conflicting arguments regarding the pathogenicity of these antibodies.
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Affiliation(s)
- Aude Chefdeville
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France
| | - Jérôme Honnorat
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
| | | | - Virginie Desestret
- Institut NeuroMyoGène, INSERM U1217/UMR CNRS 5310, Lyon, France.,Université de Lyon, Lyon, France.,French Reference Center on Paraneoplastic Neurological Syndrome, F-69677, Bron, France.,Department of Neurology, Hospices Civils de Lyon, Hôpital Neurologique, F-69677, Bron, France
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De Bruijn MAAM, Titulaer MJ. Anti-NMDAR encephalitis and other glutamate and GABA receptor antibody encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:199-217. [PMID: 27112679 DOI: 10.1016/b978-0-444-63432-0.00012-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Over the last few year, antibodies to various central nervous system receptors, particularly the glutamate and γ-aminobutyric acid (GABA) receptors, have been found to be associated with autoimmune neurologic disorders. The receptors include the N-methyl-d-aspartate receptor (NMDAR), the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), the metabotropic glutamate receptors (mGluRs), and GABA type A and B receptors (respectively GABAAR and GABABR). Compared to the previously described paraneoplastic antibodies directed at intracellular targets, the patients with receptor antibodies are often younger, they less frequently have malignancies, and they respond better to immunotherapy. Many of the patients have limbic encephalitis with amnesia, disorientation, seizures, and psychological or psychiatric symptoms, but those with NMDAR antibodies usually develop a more widespread form of encephalitis, often leading to a decrease in consciousness and requirement for long-term intensive care treatment. The autoantibodies bind directly to the synaptic or extrasynaptic receptors on the membrane surface, and have direct effects on signal transduction in central synapses. These conditions are very important to recognize as the symptoms and complications can be fatal when not treated in time, whereas with immunotherapy many patients recover considerably.
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Affiliation(s)
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW This review describes the main types of autoimmune encephalitis with special emphasis on those associated with antibodies against neuronal cell surface or synaptic proteins, and the differential diagnosis with infectious encephalitis. RECENT FINDINGS There is a continuous expansion of the number of cell surface or synaptic proteins that are targets of autoimmunity. The most recently identified include the metabotropic glutamate receptor 5 (mGluR5), dipeptidyl-peptidase-like protein-6 (DPPX), and γ-aminobutyric acid-A receptor (GABAAR). In these and previously known types of autoimmune encephalitis [N-methyl-D-aspartate receptor (NMDAR), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), γ-aminobutyric acid-B receptor (GABABR), leucine-rich glioma inactivated protein 1 (LGI1), contactin-associated protein-like 2 (CASPR2)], the prodromal symptoms or types of presentations often suggest a viral encephalitis. We review here clues that help in the differential diagnosis with infectious encephalitis. Moreover, recent investigations indicate that viral encephalitis (e.g., herpes simplex) can trigger synaptic autoimmunity. In all these disorders, immunotherapy is usually effective. SUMMARY Autoimmune encephalitis comprises an expanding group of potentially treatable disorders that should be included in the differential diagnosis of any type of encephalitis. VIDEO ABSTRACT http://links.lww.com/CONR/A25,
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