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Gombolay G, Brenton JN, Yang JH, Stredny CM, Kammeyer R, Fisher KS, Sandweiss AJ, Erickson TA, Kannan V, Otten C, Steriade C, Vu N, Santoro JD, Robles-Lopez K, Goodrich R, Otallah S, Arellano J, Christiana A, Morris M, Gorman MP, Kornbluh AB, Kahn I, Sepeta L, Jiang Y, Muscal E, Murray KO, Moodley M, Hardy D. Isolated Psychiatric Symptoms in Children With Anti-N-Methyl-d Aspartate Receptor Encephalitis. Pediatr Neurol 2024; 159:12-15. [PMID: 39094249 PMCID: PMC11381152 DOI: 10.1016/j.pediatrneurol.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/25/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Isolated psychiatric symptoms can be the initial symptom of pediatric anti-N-methyl-d-aspartate (NMDA) receptor autoimmune encephalitis (pNMDARE). Here we report on the prevalence of isolated psychiatric symptoms in pNMDARE. We also assess whether initial neurodiagnostic tests (brain magnetic resonance imaging [MRI], electroencephalography [EEG], and/or cerebrospinal fluid [CSF] white blood cell count) are abnormal in children with isolated psychiatric symptoms and pNMDARE. METHODS This multicenter retrospective cohort study from CONNECT (Conquering Neuroinflammation and Epilepsies Consortium) from 14 institutions included children under age 18 years who were diagnosed with pNMDARE. Descriptive statistics using means, medians, and comparisons for continuous versus discrete data was performed. RESULTS Of 249 children included, 12 (5%) had only psychiatric symptoms without other typical clinical features of autoimmune encephalitis at presentation. All but one (11 of 12 = 92%) had at least one abnormal finding on initial ancillary testing: eight of 12 (67%) had an abnormal EEG, six of 12 (50%) had an abnormal MRI, and five of 12 (42%) demonstrated CSF pleocytosis. The single patient with a normal MRI, EEG, and CSF profile had low positive CSF NMDA antibody (titer of 1:1), and symptoms improved without immunotherapy. CONCLUSIONS Isolated first-episode psychiatric symptoms in pNMDARE are uncommon, and the majority of children will exhibit additional neurodiagnostic abnormalities. Delaying immunotherapy in a child with isolated psychiatric symptoms and normal neurodiagnostic testing may be warranted while awaiting confirmatory antibody testing.
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Affiliation(s)
- Grace Gombolay
- Department of Pediatrics, Emory University SOM and Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - J Nicholas Brenton
- Division of Pediatric Neurology, Department of Neurology, University of Virginia Health System, Charlottesville, Virginia
| | - Jennifer H Yang
- Department of Pediatrics, University of California San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Coral M Stredny
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan Kammeyer
- Department of Pediatrics, University of Colorado SOM and Children's Hospital Colorado, Denver, Colorado
| | - Kristen S Fisher
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Alexander J Sandweiss
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Timothy A Erickson
- Section of Pediatric Tropical Medicine, Department of Pediatrics, Center for Human Immunobiology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; Laboratories for Emerging and Tropical Diseases, School of Public Health, Texas A&M University, College Station, Texas
| | - Varun Kannan
- Department of Pediatrics, Emory University SOM and Children's Healthcare of Atlanta, Atlanta, Georgia; Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Catherine Otten
- Department of Pediatrics, Seattle Children's/University of Washington, Seattle, Washington
| | - Claude Steriade
- Department of Neurology, New York University SOM, New York, New York
| | - NgocHanh Vu
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Santoro
- Department of Neurology and Pediatrics, Children's Hospital Los Angeles; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Karla Robles-Lopez
- Department of Pediatrics, University of Texas at Austin and Dell Medical School, Austin, Texas
| | - Robert Goodrich
- Department of Neurology, Atrium Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Scott Otallah
- Department of Neurology, Atrium Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Janetta Arellano
- Pediatric Neurology, Children's Hospital of Orange County, Orange, California
| | - Andrew Christiana
- Department of Neurology, New York University SOM, New York, New York
| | - Morgan Morris
- Department of Pediatrics, Emory University SOM and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexandra B Kornbluh
- Department of Pediatrics, Children's National Hospital, George Washington University Medical School, Washington, District of Columbia
| | - Ilana Kahn
- Department of Pediatrics, Children's National Hospital, George Washington University Medical School, Washington, District of Columbia
| | - Leigh Sepeta
- Department of Pediatrics, Children's National Hospital, George Washington University Medical School, Washington, District of Columbia
| | - Yike Jiang
- Section of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Eyal Muscal
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; Section of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Kristy O Murray
- Section of Pediatric Tropical Medicine, Department of Pediatrics, Center for Human Immunobiology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Manikum Moodley
- Department of Pediatrics, University of Texas at Austin and Dell Medical School, Austin, Texas
| | - Duriel Hardy
- Department of Pediatrics, University of Texas at Austin and Dell Medical School, Austin, Texas
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Treiman G, Blackwell L, Howarth R, Gombolay G. Rate of Autoimmune Encephalitis in Children With First-Episode Psychosis. Pediatr Neurol 2024; 161:113-116. [PMID: 39368246 DOI: 10.1016/j.pediatrneurol.2024.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/11/2023] [Accepted: 09/10/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Autoimmune encephalitis (AE) can present as first-episode psychosis (FEP) in children. An FEP diagnostic algorithm has been proposed, but how this algorithm applies to children is unknown. We assess the FEP diagnostic algorithm in children with FEP. METHODS The FEP algorithm was applied to a retrospective cohort of children with FEP without other neurological symptoms. RESULTS Twenty-four patients were included, with five AE (anti-N-methyl-d-aspartate receptor encephalitis) and 19 non-AE patients (12 primary psychiatric, two headaches, mycoplasma-related encephalitis, post-coronavirus disease 2019 encephalitis, drug reaction with eosinophilia and systemic symptoms [DRESS] syndrome, cobalamin C deficiency, and two unknown). Some non-AE patients (five of 19 = 26%) received immunotherapies, with symptom resolution in one of five (20%) with immunotherapy and in four of 14 (29%) without immunotherapy. The FEP algorithm recommended cerebrospinal fluid (CSF) testing in all (five of five = 100%) patients with AE and in six of 19 (32%) non-AE patients, resulting in 100% sensitivity (95% confidence interval [CI]: 100% to 100%) and 45.5% specificity (95% CI: 16% to 75%), with a negative predictive value of 100% (95% CI: 100% to 100%). CONCLUSIONS FEP can occur in children from different causes, including AE and metabolic conditions. Evaluation of FEP should be broad, especially without CSF evidence of inflammation. The FEP algorithm is useful to assess patients who would benefit from CSF testing and should be assessed in larger cohorts.
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Affiliation(s)
| | - Laura Blackwell
- Division of Pediatric Neurology, Department of Pediatrics, Emory University School of Medicine; Department of Pediatric Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Robyn Howarth
- Division of Pediatric Neurology, Department of Pediatrics, Emory University School of Medicine; Department of Pediatric Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Grace Gombolay
- Division of Pediatric Neurology, Department of Pediatrics, Emory University School of Medicine; Department of Pediatric Neurology, Children's Healthcare of Atlanta, Atlanta, Georgia.
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Kim A, Kim M, Baek JY, Lee JY, Kim SH, Kang JM, Ahn JG, Kang HC. Aetiology and Prognosis of Encephalitis in Korean Children: A Retrospective Single-Centre Study, 2005-2020. Yonsei Med J 2024; 65:78-88. [PMID: 38288648 PMCID: PMC10827636 DOI: 10.3349/ymj.2023.0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/25/2023] [Accepted: 10/16/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Encephalitis is a heterogeneous syndrome that occurs in childhood and is not rare. However, epidemiological studies of encephalitis based on the International Encephalitis Consortium (ICS) and expert recommendations are lacking. We investigated the aetiology and prognosis of encephalitis in Korean children. MATERIALS AND METHODS This retrospective study included children aged <19 years hospitalised for encephalitis at Severance Children's Hospital between 2005 and 2020. The 2013 ICS criteria were used to diagnose encephalitis, and causality was classified according to the site from which the specimen was obtained. Neurological sequelae were categorised using the modified Rankin Scale (mRS) score. RESULTS In total, 551 children were included, with 7% classified as possible, 77% as probable, and 15% as proven cases. A cause was identified in 42% of the cases (n=222), with viruses being the most common (42%), followed by bacteria (38%) and autoimmune encephalitis (12%). In cases of proven/probable encephalitis (n=65), bacteria accounted for 52%, followed by viruses (25%) and autoimmune encephalitis (22%). In cases with a single pathogen, the anti-N-methyl-D-aspartate receptor autoantibody (n=14) was the most common, followed by Group B streptococcus (n=13), herpes simplex virus (n=11), enterovirus (n=4), and others. Approximately 37% of patients had severe sequelae (mRS score ≥3) at discharge, which decreased to 31% 6 months after discharge. CONCLUSION This large-scale study showed that autoimmune and infectious causes accounted for a significant proportion of encephalitis in Korean children. Further studies are needed to determine whether early targeted treatment following early diagnosis leads to a favourable prognosis in these populations.
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Affiliation(s)
- Ahra Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Minyoung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Yeon Baek
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Young Lee
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hee Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Seoul, Korea.
| | - Ji-Man Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul, Korea.
| | - Jong Gyun Ahn
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon-Chul Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Seoul, Korea
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Santoro JD, Jafarpour S, Boyd NK, Nguyen L, Khoshnood MM. The Impact of Neuroimmunologic Disease and Developing Nervous System. Pediatr Neurol 2023; 148:189-197. [PMID: 37442652 DOI: 10.1016/j.pediatrneurol.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/16/2023] [Accepted: 06/10/2023] [Indexed: 07/15/2023]
Abstract
Over the last two decades, neuroimmunologic disorders of childhood have been increasingly described, phenotyped, and treated. These disorders remain rare in the general population and while sharing common therapeutic interventions due to their immune pathophysiology, are heterogeneous with regard to presentation and risk of recurrence. As such, the impact of these disorders on the developing brain has come into the forefront of emerging research in pediatric neuroimmunology. Investigations into the singular impact of monophasic disease on long-term development and the impact of early and aggressive disease-modifying therapy in relapsing conditions are quickly becoming areas of ripe investigation as the field's most optimal way to treat and monitor these conditions over time. Although critically important in evaluating the developing brain, research has been heterogeneous among these diseases and limited by small cohort size. This narrative review details the role of common neuroimmunologic disorders in long-term neurological and cognitive outcomes in children as they develop.
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Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Natalie K Boyd
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Lina Nguyen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Mellad M Khoshnood
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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Gombolay G, Morris M, Loerinc L, Blackwell L, Howarth R. Sleep Characteristics in Pediatric Anti- N-methyl-d-aspartate (NMDA) Receptor Encephalitis: A Retrospective Cohort Study. J Child Neurol 2023; 38:298-306. [PMID: 37203168 PMCID: PMC10524468 DOI: 10.1177/08830738231173603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Background: Rates of sleep problems in children with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis are unknown. Methods: We used a retrospective observational cohort database of children with a diagnosis of NMDA receptor encephalitis at a single freestanding institution. One-year outcomes were assessed with the pediatric modified Rankin Score (mRS), with 0 to 2 as good and 3 or greater as poor outcome. Results: Ninety-five percent (39/41) of children with NMDA receptor encephalitis had sleep dysfunction at onset; 34% (11/32) reported sleep problems at 1 year. Sleep problems at onset and propofol use were not associated with poor outcomes at 1 year. Poor sleep at 1 year correlated with mRS scores (range 2-5) at 1 year. Discussion: High rates of sleep dysfunction occur in children with NMDA receptor encephalitis. Persistent sleep problems at 1 year may correlate with outcomes as assessed by mRS at 1 year. Further studies comparing the relationship of poor sleep with outcomes in NMDA receptor encephalitis are needed.
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Affiliation(s)
- Grace Gombolay
- Department of Pediatric Neurology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
| | - Morgan Morris
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
| | - Leah Loerinc
- Emory University School of Medicine, Atlanta, GA, USA
| | - Laura Blackwell
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
- Department of Pediatric Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Robyn Howarth
- Department of Pediatric Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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