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Sansevere AJ, Henderson LA, Stredny CM, Prabhu SP, Shah A, Sundel R, Madsen J, Dufreney C, Poduri A, Gorman MP. Posterior-onset Rasmussen's encephalitis with ipsilateral cerebellar atrophy and uveitis resistant to rituximab. Epilepsy Behav Rep 2020; 14:100360. [PMID: 32368732 PMCID: PMC7184158 DOI: 10.1016/j.ebr.2020.100360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023] Open
Abstract
Rasmussen encephalitis (RE) is a disorder characterized by drug-resistant seizures and progressive unihemispheric atrophy, hemiparesis, and varying degrees of cognitive decline. The pathophysiology of RE remains elusive, with hypotheses suggesting underlying autoimmune- and T cell-mediated processes. In this case report, we describe a single patient's clinical course from the first day of presentation until definitive treatment for atypical Rasmussen encephalitis at a tertiary care pediatric center. The patient exhibited several atypical features of Rasmussen encephalitis, including a posterior predominance of initial seizure onset with the development of severe choreoathetosis and ipsilateral cerebellar atrophy. He subsequently developed coexistent autoimmune disorders in the form of psoriasis and uveitis, and underwent multiple forms of immunotherapy with limited benefit. This patient shows an association of RE with other autoimmune conditions supporting an autoimmune mechanism of disease while exhibiting several atypical features of RE. Rarely, occipital lobe seizures have been documented as the presenting semiology of this syndrome. This case highlights the need to be mindful of atypical features that may delay hemispherectomy, which remains the definitive treatment. It also suggests that children may be predisposed to the development of autoimmune disorders in later stages of the disease. Occipital seizure localization and semiology should not dissuade the diagnosis of Rasmussen's encephalitis Movement disorders, can accompany Rasmussen's encephalitis Ipsilateral cerebellar atrophy has been described in Rasmussen's encephalitis Children with Rasmussen's encephalitis may be predisposed to autoimmune disorders in the later stages of the disease
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Affiliation(s)
- Arnold J Sansevere
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Coral M Stredny
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ankoor Shah
- Department of Ophthalmology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert Sundel
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | | | - Annapurna Poduri
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Abstract
Seizures are a common manifestation of autoimmune limbic encephalitis and multifocal paraneoplastic disorders. Accumulating evidence supports an autoimmune basis for seizures in the absence of syndromic manifestations of encephalitis. The autoimmune epilepsies are immunologically mediated disorders in which recurrent seizures are a primary and persistent clinical feature. When other etiologies have been excluded, an autoimmune etiology is suggested in a patient with epilepsy upon detection of neural autoantibodies and/or the presence of inflammatory changes on cerebrospinal fluid (CSF) or magnetic resonance imaging. In such patients, immunotherapy may be highly effective, depending on the particular autoimmune epilepsy syndrome present. In this chapter, several autoimmune epilepsy syndromes are discussed. First, epilepsies secondary to other primary autoimmune disorders will be discussed, and then those associated with antibodies that are likely to be pathogenic, such as voltage-gated potassium channel-complex and N-methyl-d-aspartate receptor, gamma-aminobutyric acid A and B receptor antibodies. For each syndrome, the typical clinical, imaging, electroencephaloram, CSF, and serologic features, and pathophysiology and treatment are described. Finally, suggested guidelines for the recognition, evaluation, and treatment of autoimmune epilepsy syndromes are provided.
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Amrom D, Kinay D, Hart Y, Berkovic SF, Laxer K, Andermann F, Andermann E, Bar-Or A. Rasmussen encephalitis and comorbid autoimmune diseases: A window into disease mechanism? Neurology 2014; 83:1049-55. [PMID: 25142901 DOI: 10.1212/wnl.0000000000000791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To describe a potential association between comorbid autoimmune disease and Rasmussen encephalitis (RE) and discuss potential insights into underlying RE pathogenesis. METHODS We report a case series of 4 patients with RE in whom a comorbid autoimmune disease was subsequently diagnosed and review the literature on possible common susceptibility factors. RESULTS In 4 patients who presented with typical clinical features of RE, a comorbid autoimmune disease was subsequently diagnosed: Hashimoto thyroiditis, ulcerative colitis, Crohn disease, and systemic lupus erythematosus. We discuss the possible common predisposing factors. CONCLUSIONS The association of RE, a rare entity, with a comorbid autoimmune disease raises the possibility of shared mechanisms of susceptibility, including common immunogenetic and/or environmental risk factors.
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Affiliation(s)
- Dina Amrom
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco.
| | - Demet Kinay
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Yvonne Hart
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Samuel F Berkovic
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Ken Laxer
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Frederick Andermann
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Eva Andermann
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco
| | - Amit Bar-Or
- From the Neurogenetics Unit (D.A., E.A.), Epilepsy Clinic (F.A.), and Neuroimmunology Unit (A.B.-O.), Montreal Neurological Hospital and Institute, Quebec, Canada; Departments of Neurology & Neurosurgery (D.A., F.A., E.A., A.B.-O.), Pediatrics (F.A.), and Human Genetics (E.A.), McGill University, Montreal, Quebec, Canada; Okmeydani Education and Research Hospital (D.K.), Istanbul, Turkey; Royal Victoria Infirmary (Y.H.), Newcastle-upon-Tyne, UK; Epilepsy Research Center (S.F.B.), Department of Medicine (Neurology), University of Melbourne, Australia; and Department of Neurology (K.L.), University of California at San Francisco.
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