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Hacohen Y. Pediatric Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1160-1188. [PMID: 39088292 DOI: 10.1212/con.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article discusses common principles in diagnosing and managing autoimmune neurologic conditions in children. LATEST DEVELOPMENTS The key to improving outcomes in all patients with autoimmune neurologic diseases is making an early diagnosis, promptly initiating treatment, and identifying patients who will benefit from long-term maintenance treatment. Some neuroinflammatory syndromes can be diagnosed with an antibody biomarker (eg, aquaporin-4 antibodies, N-methyl-d-aspartate [NMDA] receptor antibodies), whereas others require clinical diagnostic criteria (eg, multiple sclerosis, opsoclonus-myoclonus syndrome). A proportion of children will be labeled as seronegative, and further investigations for other inflammatory or monogenetic etiologies need to be carried out in parallel with treating the central nervous system inflammation. Time to treatment and treatment escalation were shown to correlate with outcomes in many patients with these disorders. The choice and duration of treatment should be evaluated considering side effects and risks in the short and long terms. The presence of a highly inflammatory disease process in children supports the use of highly effective disease-modifying therapies in pediatrics. ESSENTIAL POINTS The phenotypes of pediatric autoimmune neurologic conditions may change across different age groups, as the brain is still actively developing. In general, the presentation in children is more inflammatory, but overall disability is lower, likely because of better neuroplasticity and repair. Convincing evidence has increasingly emerged to support the biological rationale that effective immunosuppressive therapies used in adult neuroimmunology are equally effective in children.
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Fisher KS, Illner A, Kannan V. Pediatric neuroinflammatory diseases in the intensive care unit. Semin Pediatr Neurol 2024; 49:101118. [PMID: 38677797 DOI: 10.1016/j.spen.2024.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 04/29/2024]
Abstract
Inflammatory disorders of the central nervous system (CNS) include a wide spectrum of autoimmune, autoinflammatory, and paraneoplastic diseases. While many affected patients require acute hospital admission, a subset may present with severe neurological symptoms requiring intensive care unit (ICU) escalation due to disordered consciousness, respiratory failure, status epilepticus, intracranial hypertension, and/or severe autonomic dysregulation.
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Affiliation(s)
- Kristen S Fisher
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, Texas.
| | - Anna Illner
- Department of Radiology, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Varun Kannan
- Division of Pediatric Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Lu D, Wang Y, Yang Y, Zhang H, Fan X, Chen S, Wei P, Shan Y, Zhao G. Thyroid function and epilepsy: a two-sample Mendelian randomization study. Front Hum Neurosci 2024; 17:1295749. [PMID: 38298204 PMCID: PMC10827972 DOI: 10.3389/fnhum.2023.1295749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024] Open
Abstract
Background Thyroid hormones (THs) play a crucial role in regulating various biological processes, particularly the normal development and functioning of the central nervous system (CNS). Epilepsy is a prevalent neurological disorder with multiple etiologies. Further in-depth research on the role of thyroid hormones in epilepsy is warranted. Methods Genome-wide association study (GWAS) data for thyroid function and epilepsy were obtained from the ThyroidOmics Consortium and the International League Against Epilepsy (ILAE) Consortium cohort, respectively. A total of five indicators of thyroid function and ten types of epilepsy were included in the analysis. Two-sample Mendelian randomization (MR) analyses were conducted to investigate potential causal relations between thyroid functions and various epilepsies. Multiple testing correction was performed using Bonferroni correction. Heterogeneity was calculated with the Cochran's Q statistic test. Horizontal pleiotropy was evaluated by the MR-Egger regression intercept. The sensitivity was also examined by leave-one-out strategy. Results The findings indicated the absence of any causal relationship between abnormalities in thyroid hormone and various types of epilepsy. The study analyzed the odds ratio (OR) between thyroid hormones and various types of epilepsy in five scenarios, including free thyroxine (FT4) on focal epilepsy with hippocampal sclerosis (IVW, OR = 0.9838, p = 0.02223), hyperthyroidism on juvenile absence epilepsy (IVW, OR = 0.9952, p = 0.03777), hypothyroidism on focal epilepsy with hippocampal sclerosis (IVW, OR = 1.0075, p = 0.01951), autoimmune thyroid diseases (AITDs) on generalized epilepsy in all documented cases (weighted mode, OR = 1.0846, p = 0.0346) and on childhood absence epilepsy (IVW, OR = 1.0050, p = 0.04555). After Bonferroni correction, none of the above results showed statistically significant differences. Conclusion This study indicates that there is no causal relationship between thyroid-related disorders and various types of epilepsy. Future research should aim to avoid potential confounding factors that might impact the study.
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Affiliation(s)
- Di Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Yunming Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Yanfeng Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Huaqiang Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
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de Freitas Dias B, Fieni Toso F, Slhessarenko Fraife Barreto ME, de Araújo Gleizer R, Dellavance A, Kowacs PA, Teive H, Spitz M, Freire Borges Juliano A, Januzi de Almeida Rocha L, Braga-Neto P, Ribeiro Nóbrega P, Oliveira-Filho J, Maciel Dias R, de Oliveira Godeiro Júnior C, Martins Maia F, Barbosa Thomaz R, Santos ML, Sousa de Melo E, da Nóbrega Júnior AW, Lin K, Graziani Povoas Barsottini O, Endmayr V, Coelho Andrade LE, Höftberger R, Almeida Dutra L. Brazilian autoimmune encephalitis network (BrAIN): antibody profile and clinical characteristics from a multicenter study. Front Immunol 2023; 14:1256480. [PMID: 37954587 PMCID: PMC10634608 DOI: 10.3389/fimmu.2023.1256480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/04/2023] [Indexed: 11/14/2023] Open
Abstract
Background The frequency of antibodies in autoimmune encephalitis (AIE) may vary in different populations, however, data from developing countries are lacking. To describe the clinical profile of AIE in Brazil, and to evaluate seasonality and predictors of AIE in adult and pediatric patients. Methods We evaluated patients with possible AIE from 17 centers of the Brazilian Autoimmune Encephalitis Network (BrAIN) between 2018 and 2022. CSF and serum were tested with TBAs and CBAs. Data on clinical presentation, complementary investigation, and treatment were compiled. Seasonality and predictors of AIE in adult and pediatric populations were analyzed. Results Of the 564 patients, 145 (25.7%) were confirmed as seropositive, 69 (12.23%) were seronegative according to Graus, and 58% received immunotherapy. The median delay to diagnosis confirmation was 5.97 ± 10.3 months. No seasonality variation was observed after 55 months of enrolment. The following antibodies were found: anti-NMDAR (n=79, 54%), anti-MOG (n=14, 9%), anti-LGI1(n=12, 8%), anti-GAD (n=11, 7%), anti-GlyR (n=7, 4%), anti-Caspr2 (n=6, 4%), anti-AMPAR (n=4, 2%), anti-GABA-BR (n=4, 2%), anti-GABA-AR (n=2, 1%), anti-IgLON5 (n=1, 1%), and others (n=5, 3%). Predictors of seropositive AIE in the pediatric population (n=42) were decreased level of consciousness (p=0.04), and chorea (p=0.002). Among adults (n=103), predictors of seropositive AIE were movement disorders (p=0.0001), seizures (p=0.0001), autonomic instability (p=0.026), and memory impairment (p=0.001). Conclusion Most common antibodies in Brazilian patients are anti-NMDAR, followed by anti-MOG and anti-LGI1. Only 26% of the possible AIE patients harbor antibodies, and 12% were seronegative AIE. Patients had a 6-month delay in diagnosis and no seasonality was found. Findings highlight the barriers to treating AIE in developing countries and indicate an opportunity for cost-effect analysis. In this scenario, some clinical manifestations help predict seropositive AIE such as decreased level of consciousness, chorea, and dystonia among children, and movement disorders and memory impairment among adults.
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Affiliation(s)
| | | | | | | | | | | | - Helio Teive
- Hospital Universitário da Universidade Federal do Paraná, Curitiba, Brazil
| | - Mariana Spitz
- Hospital Universitário Pedro Ernesto da Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | | | | | | | | | | | | | - Katia Lin
- Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | | | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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Simonavičiutė V, Praninskienė R, Grikinienė J, Samaitienė-Aleknienė R. Anti-N-methyl-D-aspartate receptor encephalitis and positive human herpesvirus-7 deoxyribonucleic acid in cerebrospinal fluid: a case report. J Med Case Rep 2023; 17:304. [PMID: 37386616 DOI: 10.1186/s13256-023-03909-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/24/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis is a neuroautoimmune syndrome typically presenting with seizures, psychiatric symptoms, and autonomic dysfunction. Human herpesvirus-7 is often found with human herpesvirus-6 and infects leukocytes such as T-cells, monocytes-macrophages, epithelial cells, and central nervous system cells. The pathogenicity of human herpesvirus-7 is unclear. Cases of anti-N-methyl-D-aspartate receptor encephalitis with human herpesvirus-7 present in cerebrospinal fluid have been documented, but the clinical significance of this finding remains unclear. CASE PRESENTATION An 11-year-old Caucasian boy was admitted to hospital after a generalized tonic-clonic seizure. Generalized tonic seizures repeated three more times during the day of hospitalization. Blood tests showed minor ongoing inflammation, while brain computed tomography yielded normal results. Brain magnetic resonance imaging showed hyperintense focal alterations in both temporal lobes, hippocampi, and at the base of the right frontal lobe. Positive anti-N-methyl-D-aspartate receptor antibodies were found in both serum and cerebrospinal fluid. Positive novel coronavirus 2 (severe acute respiratory syndrome coronavirus 2) immunoglobulin G antibodies were found in serum. Polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 was negative. Furthermore, positive human herpesvirus-7 deoxyribonucleic acid was found in cerebrospinal fluid. The patient was treated with acyclovir, human immunoglobulin, and methylprednisolone. The seizures did not repeat, and no psychiatric symptoms were present. The patient made a full recovery. CONCLUSIONS We present a pediatric case of anti-N-methyl-D-aspartate receptor encephalitis with atypical clinical presentation. The role of human herpesvirus-7 in neurological disorders remains unclear in immunocompetent patients.
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Gong Z, Lao D, Huang F, Lv S, Mao F, Huang W. Risk Factors and Prognosis in Anti-NMDA Receptor Encephalitis Patients with Disturbance of Consciousness. Patient Relat Outcome Meas 2023; 14:181-192. [PMID: 37337520 PMCID: PMC10277025 DOI: 10.2147/prom.s411260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/04/2023] [Indexed: 06/21/2023] Open
Abstract
Purpose Disturbance of consciousness is common in patients with severe anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. However, little is known about it. This study aimed to analyze the clinical manifestations and prognostic factors of anti-NMDAR encephalitis with disturbance of consciousness. Methods In this retrospective study, the clinical features, treatment results, and long-term outcomes of anti-NMDAR encephalitis patients with disturbance of consciousness were analyzed, and multivariate logistic regression was used to analyze the factors affecting their prognosis. Results In the group with disturbance of consciousness, the incidences of seizures, involuntary movements, pulmonary infection, mechanical ventilation, intensive care unit (ICU) admission, neutrophil-lymphocyte ratio (NLR), abnormal cerebrospinal fluid index, plasma exchange, and immunosuppressive therapy were higher than those in the group without disturbance of consciousness (all P<0.05). During the follow-up period (median: 36 months, range: 12-78 months), the modified Rankin scale (mRS) score, the maximum mRS score during hospitalization, the mRS score at discharge, and the mRS score at 12 months after discharge were higher in the disturbance of consciousness group (all P < 0.001). However, there was no significant difference in long-term outcomes and recurrence between the two groups. Multivariate logistic regression analysis showed that mechanical ventilation, elevated IgG index, and delayed immunotherapy were independent risk factors for poor outcomes in patients with anti-NMDAR encephalitis with disturbance of consciousness at 12 months (odds ratio: 22.591, 39.868, 1.195). The receiver operating characteristics (ROC) curve analysis showed that the area under the curve (AUC) of mechanical ventilation, elevated IgG index, and delayed immunotherapy was 0.971 (95% CI=0.934-1.000, P<0.001). Conclusion Mechanical ventilation, elevated IgG index, and delayed immunotherapy may be the influencing factors of poor prognosis of anti-NMDAR encephalitis patients with disturbance of consciousness. Although their condition is relatively serious, most patients with anti-NMDAR encephalitis with disturbance of consciousness will achieve favorable long-term outcomes after long-term treatment.
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Affiliation(s)
- Zhuowei Gong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Dayuan Lao
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Fang Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Sirao Lv
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Fengping Mao
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Wen Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
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Aboseif A, Toljan K, Mahadeen A, Zeft A, Moosa AN, Pestana-Knight E, Abrams A. Pediatric anti-NMDA-receptor autoimmune encephalitis in siblings: Developmental, Electrophysiologic, and Genetic Implications. J Neuroimmunol 2023; 379:578107. [PMID: 37207440 DOI: 10.1016/j.jneuroim.2023.578107] [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: 02/18/2023] [Revised: 03/26/2023] [Accepted: 05/14/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Anti-NMDAR encephalitis is a leading cause of autoimmune encephalitis in children. Untreated disease can lead to long-term neurological disability. CASE REPORT We present siblings with pediatric-onset anti-NMDAR encephalitis. One was treated early, while the other's diagnosis and treatment were delayed by several years. Developmental, electrophysiologic, and genetic implications are discussed. CONCLUSION Anti-NMDAR encephalitis is a severely debilitating disease that often requires prompt initiation and early escalation in treatment. Delayed treatment may lead to irreversible neurological sequalae. Further studies exploring associations between timing and tier of treatment initiation and longitudinal outcomes are needed.
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Affiliation(s)
- Albert Aboseif
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Karlo Toljan
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmad Mahadeen
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Zeft
- Department of Pediatric Rheumatology, Pediatric Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Abrams
- Department of Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Nikolaus M, Rausch P, Rostásy K, Bertolini A, Wickström R, Johannsen J, Denecke J, Breu M, Schimmel M, Diepold K, Haeusler M, Quade A, Berger A, Rosewich H, Steen C, von Au K, Dreesmann M, Finke C, Bartels F, Kaindl AM, Schuelke M, Knierim E. Retrospective Pediatric Cohort Study Validates NEOS Score and Demonstrates Applicability in Children With Anti-NMDAR Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200102. [PMID: 36948591 PMCID: PMC10032577 DOI: 10.1212/nxi.0000000000200102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/18/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) is the most common form of autoimmune encephalitis in children and adults. Although our understanding of the disease mechanisms has progressed, little is known about estimating patient outcomes. Therefore, the NEOS (anti-NMDAR Encephalitis One-Year Functional Status) score was introduced as a tool to predict disease progression in NMDARE. Developed in a mixed-age cohort, it currently remains unclear whether NEOS can be optimized for pediatric NMDARE. METHODS This retrospective observational study aimed to validate NEOS in a large pediatric-only cohort of 59 patients (median age of 8 years). We reconstructed the original score, adapted it, evaluated additional variables, and assessed its predictive power (median follow-up of 20 months). Generalized linear regression models were used to examine predictability of binary outcomes based on the modified Rankin Scale (mRS). In addition, neuropsychological test results were investigated as alternative cognitive outcome. RESULTS The NEOS score reliably predicted poor clinical outcome (mRS ≥3) in children in the first year after diagnosis (p = 0.0014) and beyond (p = 0.036, 16 months after diagnosis). A score adapted to the pediatric cohort by adjusting the cutoffs of the 5 NEOS components did not improve predictive power. In addition to these 5 variables, further patient characteristics such as the "Herpes simplex virus encephalitis (HSE) status" and "age at disease onset" influenced predictability and could potentially be useful to define risk groups. NEOS also predicted cognitive outcome with higher scores associated with deficits of executive function (p = 0.048) and memory (p = 0.043). DISCUSSION Our data support the applicability of the NEOS score in children with NMDARE. Although not yet validated in prospective studies, NEOS also predicted cognitive impairment in our cohort. Consequently, the score could help identify patients at risk of poor overall clinical outcome and poor cognitive outcome and thus aid in selecting not only optimized initial therapies for these patients but also cognitive rehabilitation to improve long-term outcomes.
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Affiliation(s)
- Marc Nikolaus
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Philipp Rausch
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Kevin Rostásy
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Annikki Bertolini
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Ronny Wickström
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Jessika Johannsen
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Jonas Denecke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Markus Breu
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Mareike Schimmel
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Katharina Diepold
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Martin Haeusler
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Annegret Quade
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Andrea Berger
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Hendrik Rosewich
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Claudia Steen
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Katja von Au
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Mona Dreesmann
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Carsten Finke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Frederik Bartels
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Angela M Kaindl
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Markus Schuelke
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
| | - Ellen Knierim
- From the Department of Pediatric Neurology (M.N., A.M.K., M.S., E.K.) and Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH); Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel; Department of Genetics and Bioinformatics (P.R.), Kiel; Department of Pediatric Neurology (K.R., A.B.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Neuropediatric Unit (R.W.), Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Pediatrics (J.J., J.D.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine (M.B.), Medical University of Vienna, Austria; Department of Pediatric Neurology (M.S.), University Children's Hospital Augsburg; Division of Pediatric Neurology, Department of Pediatrics (K.D.), Hospital Kassel; Department of Pediatrics (M.H., A.Q.), Division of Neuropediatrics and Social Pediatrics, Medical University Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen; Division of Pediatric Neurology, Department of Pediatrics (A.B.), München Klinik Harlaching, Munich; Department of Pediatrics and Pediatric Neurology (H.R.), Georg August University, Göttingen; Department of Paediatric and Adolescent Medicine (C.S.), St Joseph Hospital, Berlin; Department of Pediatrics (K.v.), Vivantes Hospital Friedrichshain, Berlin; Department of Pediatrics (M.D.), Ernst von Bergmann Hospital, Potsdam; Department of Neurology (C.F., F.B.), Charité-Universitätsmedizin Berlin and Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin (A.M.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Cell Biology and Neurobiology; Charité-Universitätsmedizin Berlin (M.S., E.K.), Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), NeuroCure Clinical Research Center Berlin, Germany
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9
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Hersh N, Ben Zvi H, Goldstein L, Steiner I, Benninger F. Epilepsy following herpes simplex encephalitis - A case series. Epilepsy Res 2023; 192:107137. [PMID: 37060749 DOI: 10.1016/j.eplepsyres.2023.107137] [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: 01/25/2023] [Revised: 03/25/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is associated with severe mortality and morbidity. Its incidence is estimated at 1:250 000, and the typical symptomatology of acute disease including headaches, mental state disturbances, confusion, sleepiness, and seizures. The chronic phase of the disease is occasionally characterized by epilepsy and neurological deficits. STUDY RATIONALE The present retrospective single-center study aims to identify risk factors for predicting the development of epilepsy (epileptogenesis) following HSE. METHODS Medical records were screened for patients older than 18 years, hospitalized between January 2005 and September 2019 with a diagnosis of "encephalitis" and "herpes simplex virus, HSV" infection. HSE diagnosis was based on an analysis of the cerebrospinal fluid with positive HSV testing results. RESULTS Twenty-three patients fit our inclusion criteria: fever and behavioral changes, followed by seizures, were reported in 58.3 % of patients. On follow-up (59.7 ± 38.8 months), eight patients (34.8 %) developed epilepsy. Pathological imaging and EEG were correlated with acute symptomatic seizures (ASS). ASS was associated with an 8-fold risk increase to develop post-encephalitis epilepsy (PE). PE was associated with younger age but not with CSF results, imaging, or EEG. CONCLUSION Our retrospective single-center study on PE, following HSE, shows that younger age and ASS were associated with PE. Brain imaging, CSF analysis, and EEG were not associated with the development of epilepsy following HSE.
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Affiliation(s)
- Nir Hersh
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Neurology Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel
| | - Haim Ben Zvi
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel
| | - Lilach Goldstein
- Department of Neurology, Tel Aviv Sourasky Medical Center, Ichilov Hospital, Tel Aviv, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel
| | - Israel Steiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel
| | - Felix Benninger
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel.
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10
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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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11
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Shivaram S, Gupta M, Taallapalli AVR, Nashi S, Mahadevan A, Srijithesh PR. A Rare Case of Anti-N-Methyl-D-Aspartate Receptor Encephalitis in an Infant Presenting with Regression and Movement Disorder. Ann Indian Acad Neurol 2023; 26:197-199. [PMID: 37179672 PMCID: PMC10170997 DOI: 10.4103/aian.aian_793_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/19/2022] [Accepted: 12/31/2022] [Indexed: 03/31/2023] Open
Affiliation(s)
- Sumanth Shivaram
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Manisha Gupta
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - A. V. R. Taallapalli
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Saraswati Nashi
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Anita Mahadevan
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - P. R. Srijithesh
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
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12
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Zhang L, Zhang L, Li F, Liu W, Tai Z, Yang J, Zhang H, Tuo J, Yu C, Xu Z. When herpes simplex virus encephalitis meets antiviral innate immunity. Front Immunol 2023; 14:1118236. [PMID: 36742325 PMCID: PMC9896518 DOI: 10.3389/fimmu.2023.1118236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/06/2023] [Indexed: 01/21/2023] Open
Abstract
Herpes simplex virus (HSV) is the most common pathogen of infectious encephalitis, accounting for nearly half of the confirmed cases of encephalitis. Its clinical symptoms are often atypical. HSV PCR in cerebrospinal fluid is helpful for diagnosis, and the prognosis is usually satisfactory after regular antiviral treatment. Interestingly, some patients with recurrent encephalitis have little antiviral effect. HSV PCR in cerebrospinal fluid is negative, but glucocorticoid has a significant effect after treatment. Specific antibodies, such as the NMDA receptor antibody, the GABA receptor antibody, and even some unknown antibodies, can be isolated from cerebrospinal fluid, proving that the immune system contributes to recurrent encephalitis, but the specific mechanism is still unclear. Based on recent studies, we attempt to summarize the relationship between herpes simplex encephalitis and innate immunity, providing more clues for researchers to explore this field further.
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Affiliation(s)
- Linhai Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Lijia Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fangjing Li
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Wanyu Liu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhenzhen Tai
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Juan Yang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Haiqing Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jinmei Tuo
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
| | - Changyin Yu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China,The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China,*Correspondence: Jinmei Tuo, ; Changyin Yu, ; Zucai Xu,
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13
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Wu PY, Chi CS, Tsai CR, Yang YL, Lee HF. Long-Term Outcome of Pediatric Patients with Anti-NMDA Receptor Encephalitis in a Single Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020182. [PMID: 36832312 PMCID: PMC9954979 DOI: 10.3390/children10020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common autoimmune encephalitis in children. There is a high probability of recovery if treated promptly. We aimed to analyze the clinical features and long-term outcomes of pediatric patients with anti-NMDA receptor encephalitis. METHOD We conducted a retrospective study with definite diagnoses of anti-NMDA receptor encephalitis in 11 children treated in a tertiary referral center between March 2012 and March 2022. Clinical features, ancillary tests, treatment, and outcomes were reviewed. RESULTS The median age at disease onset was 7.9 years. There were eight females (72.7%) and three males (27.3%). Three (27.3%) patients initially presented with focal and/or generalized seizures and eight (72.7%) with behavioral change. Seven patients (63.6%) revealed normal brain MRI scans. Seven (63.6%) had abnormal EEG results. Ten patients (90.1%) received intravenous immunoglobulin, corticosteroid, and/or plasmapheresis. After a median follow-up duration of 3.5 years, one patient was lost to follow-up at the acute stage, nine (90%) had an mRS ≤ 2, and only one had an mRS of 3. CONCLUSIONS With the early recognition of anti-NMDA receptor encephalitis based on its clinical features and ancillary tests, we were able to treat patients promptly with first-line treatment and achieve favorable neurological outcomes.
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Affiliation(s)
- Pei-Yu Wu
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Ching-Shiang Chi
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Chi-Ren Tsai
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Yao-Lun Yang
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
| | - Hsiu-Fen Lee
- Division of Pediatric Neurology, Children’s Medical Center, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sec. 4, Taichung 407, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, 250, Kuo Kuang Rd., Taichung 402, Taiwan
- Correspondence:
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14
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Yokota Y, Hara M, Oshita N, Mizoguchi T, Nishimaki H, Hao H, Nakajima H. Case report: Anti- N-methyl-D-aspartate receptor antibody-associated autoimmunity triggered by primary central nervous system B-cell lymphoma. Front Neurol 2023; 13:1048953. [PMID: 36712446 PMCID: PMC9878211 DOI: 10.3389/fneur.2022.1048953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Background We herein detail our experience with a unique patient with a primary central nervous system (PCNS) B-cell lymphoma concomitant with anti-N-methyl-d-aspartate receptor (NMDAR) antibodies that satisfied the criteria of "probable anti-NMDAR encephalitis (ProNMDARE)" based on the Graus criteria 2016. Case presentation A 73-year-old Japanese woman presented with acute pyrexia, agitation, and disturbance of consciousness. She gradually developed a reduction in speech frequency and truncal dystonia causing abnormal posture. Brain magnetic resonance imaging (MRI) demonstrated high-intensity lesions in the bilateral frontal lobes, and her cerebrospinal fluid revealed mild pleocytosis. She was diagnosed with acute encephalitis and treated with acyclovir and intravenous dexamethasone; however, no improvement was observed. She was transferred to our hospital 6 weeks after the onset of her symptoms, and anti-NMDAR antibodies were identified in her cerebrospinal fluid through indirect immunolabeling with rat brain frozen sections and cell-based assays with NR1/NR2 transfected HEK cells. Follow-up MRI showed enlargement of the lesions in the right frontal lobe with gadolinium enhancement, suggesting a brain tumor. Stereotactic surgery was implemented, with subsequent pathological examination revealing that the tumor was consistent with diffuse large B-cell lymphoma (DLBCL) without evidence of systemic satellite lesions. Stereotactic irradiative therapies were then added to her treatment regimen, which partly improved her neurological symptoms with only mild cognitive dysfunction still remaining. A decrease in anti-NMDAR antibody titer was also confirmed after immunotherapy and tumor removal. Conclusions We herein report our experience with a novel case of PCNS-DLBCL masquerading as anti-NMDAR encephalitis that satisfied the diagnostic criteria of "proNMDARE." Treatment, including tumor removal, ameliorated disease severity and antibody titers of the patient. Our findings suggest that anti-NMDAR antibody-associated autoimmunity can be triggered by PCNS B-cell tumors, although primary brain tumors need to be excluded before establishing a diagnosis of autoimmune encephalitis.
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Affiliation(s)
- Yuki Yokota
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Hara
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan,*Correspondence: Makoto Hara ✉
| | - Natsuki Oshita
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomotaka Mizoguchi
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Haruna Nishimaki
- Division of Oncologic Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroyuki Hao
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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15
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Chowdhury D, Panda AK, Gupta A, Chowdhury S, Duggal A, Koul A. Anti- N-methyl D-aspartate Receptor Encephalitis in India: A Literature Review. Ann Indian Acad Neurol 2023; 26:17-32. [PMID: 37034048 PMCID: PMC10081549 DOI: 10.4103/aian.aian_519_22] [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: 06/12/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Anti N-methyl D-aspartate receptor encephalitis (NMDAR-E) though rare, is currently considered as the commonest antibody mediated encephalitis in the world. No review on perspectives of NMDAR-E from India is available. The aim of the study was to review all the cases of NMDAR-E reported from India until June 2021 in terms of clinical features, diagnosis, and treatment, and perform a comparison of adult and paediatric cases. A literature review of NMDAR-E case reports/case series published from India till June 2021 was done. Demography, clinical profile, triggers, electroencephalography (EEG), neuroimaging, treatment details and outcomes were analysed. Sixteen case series and 35 case reports with a total of 249 cases were analysed. 82% of cases were from paediatric age group. The female to male ratio was 3:1. Psychiatric deficits, movement disorders, seizures, and language abnormalities were the most common clinical features. MRI brain abnormalities were seen in 45% patients. Electroencephalographic abnormalities were seen in 85% of patients. Infective triggers (herpes simplex virus and various other agents) were reported in 11% of the cases. Pediatric patients as compared with adults had more encephalopathy, autonomic dysfunctions, and normal imaging whereas the latter had more cognitive dysfunctions and delta brush pattern in electroencephalography (p<0.005). Therefore, to conclude, this literature review suggests that overall, the clinical spectrum of Indian cases is like cases described from other parts of the world. However, most reported cases from India belonged to paediatric age group who had more encephalopathy, autonomic dysfunctions, and normal brain imaging compared to adults. A few novel infectious agents as triggers were described from India.
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Affiliation(s)
- Debashish Chowdhury
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashwin K. Panda
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashutosh Gupta
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Samiran Chowdhury
- Department of Internal Medicine, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashish Duggal
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Arun Koul
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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16
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Kolla S, Balleda L, Thimmapuram C. Anti-N-methyl-D-Aspartate-Receptor encephalitis following herpes simplex virus encephalitis – Presenting as a pediatric patient with abnormal movements and psychiatric manifestation. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2023. [DOI: 10.4103/injms.injms_127_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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17
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Shah AA, Wolf AB, Declusin A, Coleman K, Kammeyer R, Khan B, Corboy JR. Challenging Cases in Neuroimmunology. Semin Neurol 2022; 42:695-707. [PMID: 36690027 DOI: 10.1055/s-0042-1760100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Neuroimmunology is rapidly evolving field extending from well-known, but incompletely understood conditions like multiple sclerosis, to novel antibody-mediated disorders, of which dozens have been described in the past 10 years. The ongoing expansion in knowledge needed to effectively diagnose and treat these patients presents myriad challenges for clinicians. Here, we discuss six informative cases from our institution. By highlighting these challenging cases, we hope to instill fundamental points on the nuances of diagnosis and management for conditions including tumefactive multiple sclerosis, antibody-mediated encephalitis, antiphospholipid antibody syndrome, neuromyelitis optica, and myelin oligodendrocyte glycoprotein IgG-associated disease.
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Affiliation(s)
- Anna A Shah
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
| | - Andrew B Wolf
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
| | - Anthony Declusin
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
| | - Kyle Coleman
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan Kammeyer
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
| | - Baber Khan
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
- Riverhills Neuroscience, Cincinnati, Ohio
| | - John R Corboy
- Department of Neurology, Rocky Mountain MS Center, University of Colorado School of Medicine, Aurora, Colorado
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18
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Flet-Berliac L, Tchitchek N, Lépine A, Florea A, Maurey H, Chrétien P, Hacein-Bey-Abina S, Villega F, Cheuret E, Rogemond V, Picard G, Honnorat J, Deiva K. Long-term outcome of paediatric anti-N-methyl-D-aspartate receptor encephalitis. Dev Med Child Neurol 2022; 65:691-700. [PMID: 36196688 DOI: 10.1111/dmcn.15429] [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: 12/21/2021] [Revised: 08/26/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022]
Abstract
AIM To study long-term clinical and cognitive outcomes of patients with anti-N-methyl-d-aspartate receptor encephalitis (NMDAR-E), an acute autoimmune neurological disease with severe acute presentations. METHOD In this French multicentre retrospective observational cohort study, patients no older than 18 years with a follow-up of at least 2 years were included. Data from clinical and cognitive assessments were collected. RESULTS Eighty-one patients were included (57 females, 24 males; median age 10 years 7 months [range 1-18 years], median follow-up 40 months [range 25-53 months]). At last follow-up, 35 patients (45%) had cognitive impairment, 48 (70%) had academic difficulties, and 65 (92%) needed rehabilitation. Seventy-one patients (88%) had a modified Rankin Scale score of no more than 2. A higher number of symptoms at diagnosis was associated with cognitive impairment (p = 0.01), while an abnormal electroencephalogram at diagnosis increased the risk of academic difficulties (p = 0.03). INTERPRETATION Although most children with NMDAR-E seemed to recover from motor disabilities, more than 45% had cognitive and academic difficulties. The initial severity of symptoms seems to have an impact on cognition and academic performances.
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Affiliation(s)
- Lorraine Flet-Berliac
- Pediatric Neurology Departement, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Nicolas Tchitchek
- Immunology-Immunopathology-Immunotherapy (i3), Sorbonne University INSERM, Paris, France
| | - Anne Lépine
- Pediatric Neurology Department, Assistance Publique des Hôpitaux de Marseille, Hôpital Universitaire, Marseille, France
| | - Anca Florea
- Pediatric Neurology Departement, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Hélène Maurey
- Pediatric Neurology Departement, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Pascale Chrétien
- Clinical Immunology Laboratory, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France.,UTCBS, UMR8258 CNRS-U1267 INSERM, Faculté de Pharmacie de Paris, Université de Paris
| | - Salima Hacein-Bey-Abina
- Clinical Immunology Laboratory, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France.,UTCBS, UMR8258 CNRS-U1267 INSERM, Faculté de Pharmacie de Paris, Université de Paris
| | - Frederic Villega
- Pediatric Neurology Department, CIC 0005, University Children Hospital, Bordeaux.,Interdisciplinary Institute for Neurosciences, CNRS UMR 5297
| | - Emmanuel Cheuret
- Pediatric Neurology Department, Purpan University Hospital, Toulouse, France
| | - Véronique Rogemond
- French Reference Center on autoimmune encephalitis, Hospices Civils de Lyon, Institut NeuroMyoGene, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Géraldine Picard
- French Reference Center on autoimmune encephalitis, Hospices Civils de Lyon, Institut NeuroMyoGene, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Honnorat
- French Reference Center on autoimmune encephalitis, Hospices Civils de Lyon, Institut NeuroMyoGene, Inserm U1217/CNRS UMR 5310, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Kumaran Deiva
- Pediatric Neurology Departement, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Bicêtre Hospital, and Paris-Saclay University, Le Kremlin-Bicêtre, France.,National Referral Center for rare inflammatory brain and spinal diseases, Le Kremlin-Bicêtre, France
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19
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Huong NHT, Toan ND, Quy DT, Khanh TH, Thinh LQ, Nhan LNT, Minh NNQ, Turner H, Thwaites L, Irani S, Hung NT, Tan LV. Study protocol: The clinical features, epidemiology, and causes of paediatric encephalitis in southern Vietnam. Wellcome Open Res 2022; 6:133. [PMID: 36300174 PMCID: PMC9579742 DOI: 10.12688/wellcomeopenres.16770.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
Encephalitis is a major cause of morbidity and mortality worldwide. The clinical syndrome of encephalitis consists of altered mental status, seizures, neurologic signs, and is often accompanied by fever, headache, nausea, and vomiting. The encephalitis in children has been known that more common than in adult, with the incidence rate of infants was 3.9 times higher than that of people 20-44 years of age. The reported incidence of hospitalization attributed to paediatric encephalitis ranged from 3 to 13 admissions per 100,000 children per year with the overall mortality ranging from 0 to 7%. There are however more than 100 pathogens that can cause encephalitis and accurate diagnosis is challenging. Over 50% of patients with encephalitis are left undiagnosed despite extensive laboratory investigations. Furthermore, recent studies in high-income settings have suggested autoimmune encephalitis has now surpassed infectious aetiologies, mainly due to increased awareness and diagnostic capacity, which further challenges routine diagnosis and clinical management, especially in developing countries. There are limited contemporary data on the causes of encephalitis in children in Vietnam. Improving our knowledge of the causative agents of encephalitis in this resource-constrained setting remains critical to informing case management, resource distribution and vaccination strategy. Therefore, we conduct a prospective observational study to characterise the clinical, microbiological, and epidemiological features of encephalitis in a major children's hospital in southern Vietnam. Admission clinical samples will be collected alongside meta clinical data and from each study participants. A combination of classical assays (serology and PCR) and metagenomic next-generation sequencing will used to identify the causative agents. Undiagnosed patients with clinical presentations compatible with autoimmune encephalitis will then be tested for common forms of the disease. Finally, using direct- and indirect costs, we will estimate the economic burden of hospitalization and seven days post hospital discharge of paediatric encephalitis in our setting.
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Affiliation(s)
- Nguyen Hoang Thien Huong
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam,
| | | | - Du Tuan Quy
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | - Le Quoc Thinh
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | | | - Hugo Turner
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Sarosh Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,
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20
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Huong NHT, Toan ND, Quy DT, Khanh TH, Thinh LQ, Nhan LNT, Minh NNQ, Turner H, Thwaites L, Irani S, Hung NT, Tan LV. Study protocol: The clinical features, epidemiology, and causes of paediatric encephalitis in southern Vietnam. Wellcome Open Res 2022; 6:133. [PMID: 36300174 PMCID: PMC9579742 DOI: 10.12688/wellcomeopenres.16770.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 01/13/2023] Open
Abstract
Encephalitis is a major cause of morbidity and mortality worldwide. The clinical syndrome of encephalitis consists of altered mental status, seizures, neurologic signs, and is often accompanied by fever, headache, nausea, and vomiting. The encephalitis in children has been known that more common than in adult, with the incidence rate of infants was 3.9 times higher than that of people 20-44 years of age. The reported incidence of hospitalization attributed to paediatric encephalitis ranged from 3 to 13 admissions per 100,000 children per year with the overall mortality ranging from 0 to 7%. There are however more than 100 pathogens that can cause encephalitis and accurate diagnosis is challenging. Over 50% of patients with encephalitis are left undiagnosed despite extensive laboratory investigations. Furthermore, recent studies in high-income settings have suggested autoimmune encephalitis has now surpassed infectious aetiologies, mainly due to increased awareness and diagnostic capacity, which further challenges routine diagnosis and clinical management, especially in developing countries. There are limited contemporary data on the causes of encephalitis in children in Vietnam. Improving our knowledge of the causative agents of encephalitis in this resource-constrained setting remains critical to informing case management, resource distribution and vaccination strategy. Therefore, we conduct a prospective observational study to characterise the clinical, microbiological, and epidemiological features of encephalitis in a major children's hospital in southern Vietnam. Admission clinical samples will be collected alongside meta clinical data and from each study participants. A combination of classical assays (serology and PCR) and metagenomic next-generation sequencing will used to identify the causative agents. Undiagnosed patients with clinical presentations compatible with autoimmune encephalitis will then be tested for common forms of the disease. Finally, using direct- and indirect costs, we will estimate the economic burden of hospitalization and seven days post hospital discharge of paediatric encephalitis in our setting.
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Affiliation(s)
- Nguyen Hoang Thien Huong
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam,
| | | | - Du Tuan Quy
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | - Le Quoc Thinh
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | | | - Hugo Turner
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Sarosh Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,
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21
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Huong NHT, Toan ND, Quy DT, Khanh TH, Thinh LQ, Nhan LNT, Minh NNQ, Turner H, Thwaites L, Irani S, Hung NT, Tan LV. Study protocol: The clinical features, epidemiology, and causes of paediatric encephalitis in southern Vietnam. Wellcome Open Res 2022; 6:133. [PMID: 36300174 PMCID: PMC9579742 DOI: 10.12688/wellcomeopenres.16770.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/13/2023] Open
Abstract
Encephalitis is a major cause of morbidity and mortality worldwide. The clinical syndrome of encephalitis consists of altered mental status, seizures, neurologic signs, and is often accompanied by fever, headache, nausea, and vomiting. The encephalitis in children has been known that more common than in adult, with the incidence rate of infants was 3.9 times higher than that of people 20-44 years of age. The reported incidence of hospitalization attributed to paediatric encephalitis ranged from 3 to 13 admissions per 100,000 children per year with the overall mortality ranging from 0 to 7%. There are however more than 100 pathogens that can cause encephalitis and accurate diagnosis is challenging. Over 50% of patients with encephalitis are left undiagnosed despite extensive laboratory investigations. Furthermore, recent studies in high-income settings have suggested autoimmune encephalitis has now surpassed infectious aetiologies, mainly due to increased awareness and diagnostic capacity, which further challenges routine diagnosis and clinical management, especially in developing countries. There are limited contemporary data on the causes of encephalitis in children in Vietnam. Improving our knowledge of the causative agents of encephalitis in this resource-constrained setting remains critical to informing case management, resource distribution and vaccination strategy. Therefore, we conduct a prospective observational study to characterise the clinical, microbiological, and epidemiological features of encephalitis in a major children's hospital in southern Vietnam. Admission clinical samples will be collected alongside meta clinical data and from each study participants. A combination of classical assays (serology and PCR) and metagenomic next-generation sequencing will used to identify the causative agents. Undiagnosed patients with clinical presentations compatible with autoimmune encephalitis will then be tested for common forms of the disease. Finally, using direct- and indirect costs, we will estimate the economic burden of hospitalization and seven days post hospital discharge of paediatric encephalitis in our setting.
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Affiliation(s)
- Nguyen Hoang Thien Huong
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam,
| | | | - Du Tuan Quy
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | - Le Quoc Thinh
- Children's Hospital 1, Ho Chi Minh City, 700000, Vietnam
| | | | | | - Hugo Turner
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Sarosh Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam,
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Abstract
Autoimmune encephalitis is a group of central nervous system (CNS) inflammatory disorders that most commonly affect young adults and children. These disorders are closely associated with antibodies against neuronal cell-surface proteins, receptors, and ion channels; however, some forms of the disorder have no known antibody at this time. In children, neurological manifestations such as seizure, movement disorders, and focal neurological deficits are more prominent at initial presentation than psychiatric or behavioral symptoms. When psychiatric symptoms do occur, they often manifest as temper tantrums, aggression, agitation, and rarely psychosis. Prompt diagnosis and early treatment can lead to improved outcomes and decreased relapses. First-line therapies include intravenous steroids, intravenous immunoglobulin, and plasmapheresis, whereas rituximab and cyclophosphamide are utilized for refractory or relapsing disease. This review highlights the different forms of this disorder, discusses approach to diagnosis and treatment, and reviews the outcome and prognosis of children diagnosed with different forms of autoimmune encephalitis.
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23
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Gill AJ, Venkatesan A. Pathogenic mechanisms in neuronal surface autoantibody-mediated encephalitis. J Neuroimmunol 2022; 368:577867. [DOI: 10.1016/j.jneuroim.2022.577867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 11/16/2022]
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Abstract
Autoimmune encephalitis is a common and treatable cause of encephalitis in children and adults. Individuals present with a variety of symptoms, including altered mental status, behavioral changes, irritability, insomnia, developmental regression, seizures, dyskinetic movements, and autonomic instability. Evaluation includes electroencephalography, magnetic resonance imaging, and lumbar puncture. Once infectious and other causes are reasonably ruled out, treatment should be started empirically without waiting for antibody confirmation. Early clinical suspicion is key, as the outcome depends on early initiation of immunotherapy, including corticosteroids, intravenous immunoglobulin, and/or plasmapheresis. Severe or refractory cases require other treatments, such as rituximab, cyclophosphamide, or other immunotherapies using novel monoclonal antibodies. Psychiatry should be involved early for the management of behavioral issues. Additional considerations include management of seizures and dyskinesias. ICU admission may be required for management of hypoventilation necessitating mechanical ventilation (either intrinsic or iatrogenic, eg, from sedatives), refractory seizures, and dysautonomia. Anti-N-methyl-d-aspartate receptor and other forms of autoimmune encephalitis are less often associated with neoplasia (such as ovarian teratoma) in children compared with adults, but screening and removal of tumor if present should be performed.
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Affiliation(s)
- Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angles, Los Angeles, CA
| | - Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angles, Los Angeles, CA.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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25
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Feng J, Yang M, Cui D, Huang Z, Ji T, Lian Y. Recurrence of Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Cohort Study in Central China. Front Neurol 2022; 13:832634. [PMID: 35356456 PMCID: PMC8959942 DOI: 10.3389/fneur.2022.832634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/01/2022] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate factors that could impact or predict the probability of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis recurrence in central China. Methods From November 2014 to October 2020, observational data of anti-NMDAR encephalitis inpatients in our institution were collected and analyzed prospectively. The demographics, clinical characteristics, tumor status, lesion locations on MRI and immunotherapies, etc. had entered into a Cox regression model for the identification of the factors associated with relapse-free survival. Results We enrolled 113 patients in a row (median age: 28 years, range: 1-61 years). The gender distribution was not statistically significant (p = 0.158), with 49 people (43.4%) being female. The median follow-up time was 16 (4-77) months. Among them, 16.8% of patients relapsed. The average interval between recurrences was 8 months (range 3-54 mo). The severity of the initial relapse was less severe than it had been at the start. The first relapse had considerably fewer symptoms (median 2, range 1-6) than the first episode (median 4, range 1-8, p = 0.005). The mRS at first relapse (median 3, mean 2.84, range 1-5) had been significantly lower than that at onset (median 4, mean 3.89, range 3-5, p = 0.004). The length of hospitalization at first relapse (median 17 days, range 5-46) was significantly shorter than the first episode (median 35 days, range 14-102, p = 0.002). In the survival analysis, the risk of recurrence was significantly higher for patients with a brainstem lesion (HR: 4.112, 95% CI: 1.205-14.030; p = 0.024) or ≥3 abnormal sites (HR: 2.926, 95% CI: 1.085-7.896; p = 0.034) on brain MRI at the first episode. There was no significant difference in neurological outcomes between the recurrent and monophasic groups at the most recent follow-up (mRS 0-2 in 17/19 vs. 86/94; p = 0.674). Conclusions Anti-NMDAR encephalitis can recur in around one out of every six cases, and symptoms are generally milder than when it first appears. Recurrence is not related to the severity in the acute phase or the prognosis at follow-up. Patients with ≥3 abnormal sites on MRI or lesions located in the brainstem at onset must be alert to the possibility of recurrence.
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Affiliation(s)
| | | | | | | | | | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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26
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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.
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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
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27
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Tunc EM, Otten CE, Kodish IM, Kim SJ, Kochar A, Novotny E, Yoshida H. Seventeen-Year-Old Female With History of Depression Presented With Mania and Enuresis. Pediatrics 2022; 149:184671. [PMID: 35229119 DOI: 10.1542/peds.2021-051176] [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] [Accepted: 10/07/2021] [Indexed: 11/24/2022] Open
Abstract
A 17-year-old girl with a history of depression was referred by her psychologist to the emergency department (ED) because of concerning behavioral changes for the past 2 weeks. She was engaging in erratic behaviors, including excessive baking, handling broken glass, mixing chemicals, and swimming alone while clothed. She denied any intention to harm herself or others. She was feeling energized in the morning despite only sleeping a few hours at night. She also urinated on herself the day before her ED visit. Her examination and preliminary testing findings in the ED were largely normal. Her initial presentation was concerning for a psychiatric etiology, such as new-onset bipolar disorder given previous history of depression and recent impulsive symptoms suggestive of mania. As her clinical course evolved and urinary incontinence continued, her definitive diagnosis was made by an interdisciplinary team that included child psychiatry and pediatric neurology.
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Affiliation(s)
- Emine M Tunc
- Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics
| | - Catherine E Otten
- Seattle Children's Hospital, Seattle, Washington.,Division of Pediatric Neurology, Department of Neurology, School of Medicine, University of Washington, Seattle, Washington
| | - Ian M Kodish
- Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics
| | - Soo-Jeong Kim
- Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics
| | - Angad Kochar
- Seattle Children's Hospital, Seattle, Washington.,Division of Pediatric Neurology, Department of Neurology, School of Medicine, University of Washington, Seattle, Washington
| | - Edward Novotny
- Seattle Children's Hospital, Seattle, Washington.,Division of Pediatric Neurology, Department of Neurology, School of Medicine, University of Washington, Seattle, Washington
| | - Hiromi Yoshida
- Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics
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28
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Macher S, Bsteh G, Berger T, Höftberger R. Diagnostic approach and treatment regimens in adult patients suffering from antibody-mediated or paraneoplastic encephalitis. Curr Pharm Des 2022; 28:454-467. [PMID: 35100954 DOI: 10.2174/1381612828666220131093259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Identification of patients with antibody-mediated encephalitis poses a diagnostic challenge and any delay in that respect will increase the interval until initiation of immunotherapy and may negatively affect the patient´s clinical outcome. Within this review we focus on therapeutic strategies in antibody-mediated encephalitis and propose how to proceed with patients, who are suspected to have encephalitis of unknown origin. We further briefly outline differences in treatment of paraneoplastic and antibody-mediated encephalitis according to its pathomechanisms.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
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29
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Greenlee JE, Carlson NG, Abbatemarco JR, Herdlevær I, Clardy SL, Vedeler CA. Paraneoplastic and Other Autoimmune Encephalitides: Antineuronal Antibodies, T Lymphocytes, and Questions of Pathogenesis. Front Neurol 2022; 12:744653. [PMID: 35111121 PMCID: PMC8801577 DOI: 10.3389/fneur.2021.744653] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/26/2021] [Indexed: 01/14/2023] Open
Abstract
Autoimmune and paraneoplastic encephalitides represent an increasingly recognized cause of devastating human illness as well as an emerging area of neurological injury associated with immune checkpoint inhibitors. Two groups of antibodies have been detected in affected patients. Antibodies in the first group are directed against neuronal cell surface membrane proteins and are exemplified by antibodies directed against the N-methyl-D-aspartate receptor (anti-NMDAR), found in patients with autoimmune encephalitis, and antibodies directed against the leucine-rich glioma-inactivated 1 protein (anti-LGI1), associated with faciobrachial dystonic seizures and limbic encephalitis. Antibodies in this group produce non-lethal neuronal dysfunction, and their associated conditions often respond to treatment. Antibodies in the second group, as exemplified by anti-Yo antibody, found in patients with rapidly progressive cerebellar syndrome, and anti-Hu antibody, associated with encephalomyelitis, react with intracellular neuronal antigens. These antibodies are characteristically found in patients with underlying malignancy, and neurological impairment is the result of neuronal death. Within the last few years, major advances have been made in understanding the pathogenesis of neurological disorders associated with antibodies against neuronal cell surface antigens. In contrast, the events that lead to neuronal death in conditions associated with antibodies directed against intracellular antigens, such as anti-Yo and anti-Hu, remain poorly understood, and the respective roles of antibodies and T lymphocytes in causing neuronal injury have not been defined in an animal model. In this review, we discuss current knowledge of these two groups of antibodies in terms of their discovery, how they arise, the interaction of both types of antibodies with their molecular targets, and the attempts that have been made to reproduce human neuronal injury in tissue culture models and experimental animals. We then discuss the emerging area of autoimmune neuronal injury associated with immune checkpoint inhibitors and the implications of current research for the treatment of affected patients.
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Affiliation(s)
- John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Noel G Carlson
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Geriatric Research, Education, and Clinical Center (GRECC), George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurobiology, University of Utah, Salt Lake City, UT, United States
| | - Justin R Abbatemarco
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Ida Herdlevær
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stacey L Clardy
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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30
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Sabanathan S, Abdel‐Mannan O, Mankad K, Siddiqui A, Das K, Carr L, Eltze C, Eyre M, Gadian J, Hemingway C, Kaliakatsos M, Kneen R, Krishnakumar D, Lynch B, Parida A, Rossor T, Taylor M, Wassmer E, Wright S, Lim M, Hacohen Y. Clinical features, investigations, and outcomes of pediatric limbic encephalitis: A multicenter study. Ann Clin Transl Neurol 2022; 9:67-78. [PMID: 35015932 PMCID: PMC8791799 DOI: 10.1002/acn3.51494] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE). METHODS In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records. RESULTS Twenty-five children fulfilling LE criteria were identified, with median age of 11 years (IQR 8, 14) and median follow-up of 24 months (IQR 18, 48). All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra-limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti-NMDAR Abs, and 2/15 positive for anti-Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti-GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second-line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days (IQR 11, 30). At last follow-up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long-term cognitive and epilepsy outcomes in those who received rituximab versus those who did not. INTERPRETATION A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort.
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Affiliation(s)
- Saraswathy Sabanathan
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Omar Abdel‐Mannan
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Kshitij Mankad
- Department of NeuroradiologyGreat Ormond Street Hospital for ChildrenLondon
| | - Ata Siddiqui
- Department of Neuroradiology, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
| | - Krishna Das
- Department of NeurophysiologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Lucinda Carr
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Christin Eltze
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Michael Eyre
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- School of Biomedical Engineering & Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Jon Gadian
- Department of Paediatric NeurologyKing’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Cheryl Hemingway
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Marios Kaliakatsos
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Rachel Kneen
- Department of NeurologyAlder Hey Children’s NHS Foundation TrustLiverpoolUnited Kingdom
| | - Deepa Krishnakumar
- Department of Paediatric NeurologyAddenbrooke’s HospitalCambridgeUnited Kingdom
| | - Bryan Lynch
- Department of Paediatric NeurologyChildren’s University HospitalDublinIreland
| | - Amitav Parida
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
| | - Thomas Rossor
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
| | - Micheal Taylor
- Department of Paediatric NeurologyLeeds Children’s HospitalLeedsUnited Kingdom
| | - Evangeline Wassmer
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Sukhvir Wright
- Department of NeurologyBirmingham Children’s HospitalBirminghamUnited Kingdom
- Aston Neuroscience Institute, College of Health and Life SciencesAston UniversityBirminghamUnited Kingdom
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUnited Kingdom
- King’s Health Partners Academic Health Science CentreLondonUnited Kingdom
| | - Yael Hacohen
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUnited Kingdom
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUnited Kingdom
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31
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Abdullah W, Hussein S, Ibrahim B. Anti-N-Methyl-D-Aspartate receptor encephalitis in pediatrics: A review of clinical manifestations, treatment, and prognosis. MUSTANSIRIYA MEDICAL JOURNAL 2022. [DOI: 10.4103/mj.mj_6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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32
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Haq AU, Nabi D, Alam M, Ullah SA. The Spectrum of Movement Disorders in Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis Both in Children and Adults: An Experience From a Single Tertiary Care Center. Cureus 2021; 13:e20376. [PMID: 35036209 PMCID: PMC8752382 DOI: 10.7759/cureus.20376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/09/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a form of autoimmune encephalitis. The characteristic clinical features include seizure, psychosis-like symptoms, abnormal movements, and autonomic disturbances. Patients with anti-NMDAR encephalitis can present with various types of movement disorders. Typically, the movement disorders start following intervals of psychiatric and prodromal manifestations in young adults; however, in children, these might be an early presentation of anti-NMDAR encephalitis. The disease is under-recognized and underdiagnosed in Pakistan. Early recognition of the disease is important to commence timely treatment leading to a better prognosis. Here we present a collection of anti-NMDAR encephalitis patients, specifically focussing on the different types of movement disorders and the differences in clinical manifestations between children and adults.
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33
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Cengiz AB, Günbey C, Ceyhan M, Korukluoğlu G, Tanır Başaranoğlu S, Eroğlu Ertuğrul NG, Coşgun Y, Konuşkan B, Özsürekci Y, Anlar B. Etiological and Clinical Profile of Acute Nonbacterial Encephalitis in Children: A Single-Center Prospective Study. Neuropediatrics 2021; 52:448-454. [PMID: 33578438 DOI: 10.1055/s-0041-1723954] [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] [Indexed: 10/22/2022]
Abstract
Encephalitis is a serious neurological syndrome caused by inflammation of the brain. The diagnosis can be challenging and etiology remains unidentified in about half of the pediatric cases. We aimed to investigate demographic, clinical, laboratory, electroencephalographic and neuroimaging findings, and outcome of acute encephalitis of nonbacterial etiology. This prospective study included children hospitalized with the diagnosis of acute encephalitis between 2017 and 2019. Microbiological investigations of the cerebrospinal fluid (CSF) were recorded. All CSF specimens were tested for anti-N methyl D-aspartate receptor (NMDAR) antibodies. In total, 31 children aged 10 months to 17 years (median = 6 years) were included. Pathogens were confirmed in CSF in three patients (9.7%): varicella zoster virus, herpes simplex virus type 1 (HSV-1), and both HSV-1 and NMDAR antibodies. Presenting features included encephalopathy (100%), fever (80.6%), seizure (45.2%), focal neurological signs (29%), and ataxia (19.4%). On clinical follow-up of median 9 (6-24) months, six patients showed neurological deficits: together with two patients who died in hospital, total eight (25.8%) patients were considered to have unfavorable outcome. Need for intubation, receiving immunomodulatory treatment, prolonged hospitalization, and high erythrocyte sedimentation rate at admission were associated with unfavorable outcome. The etiology of encephalitis remains unexplained in the majority of children. HSV-1 is the most frequently detected virus, consistent with the literature. The fact that anti-NMDAR encephalitis was detected in one child suggests autoimmune encephalitis not being rare in our center. The outcome is favorable in the majority while about one-fifth of cases suffer from sequelae.
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Affiliation(s)
- Ali Bülent Cengiz
- Department of Pediatric Infectious Diseases, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Ceren Günbey
- Department of Pediatric Neurology, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Mehmet Ceyhan
- Department of Pediatric Infectious Diseases, Hacettepe University Medical Faculty, Ankara, Turkey
| | | | - Sevgen Tanır Başaranoğlu
- Department of Pediatric Infectious Diseases, Hacettepe University Medical Faculty, Ankara, Turkey
| | | | - Yasemin Coşgun
- Department of Virology, Public Health Institution, Ankara, Turkey
| | - Bahadır Konuşkan
- Department of Pediatric Neurology, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Yasemin Özsürekci
- Department of Pediatric Infectious Diseases, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Banu Anlar
- Department of Pediatric Neurology, Hacettepe University Medical Faculty, Ankara, Turkey
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34
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Taylor K, Muscal E, Van Mater H. The Role of Pediatric Rheumatologists in Autoimmune Brain Disease. Rheum Dis Clin North Am 2021; 48:343-369. [PMID: 34798957 DOI: 10.1016/j.rdc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The spectrum of autoimmune and inflammatory brain diseases continues to evolve with medical advances facilitating both the detection of inflammation of the central nervous system and the discovery of novel disease mechanisms. The clinical overlap of these disorders with primary rheumatic diseases and the efficacy of immunotherapy have led to strong partnerships between pediatric rheumatologists, neurologists, psychiatrists, and other providers in the care of children with these conditions. Early diagnosis and initiation of targeted therapy improve clinical outcomes, highlighting the importance of interdisciplinary collaborative care.
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Affiliation(s)
- Kathryn Taylor
- Pediatrics, Division of Neurology, Duke University, Durham, NC, USA.
| | - Eyal Muscal
- Division of Rheumatology and Co-appointment in Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Heather Van Mater
- Pediatrics, Division of Rheumatology, Duke University, Durham, NC, USA
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35
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Wanigasinghe J, Anuradha KWDA, Chang T. Pediatric Autoimmune Encephalitis in Sri Lanka: A Single-Center Experience over 7 Years. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1739260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractPediatric autoimmune encephalitis (AE) remains a diagnostic and therapeutic challenge in resource-poor settings. Minimizing delay in diagnosis and appropriate escalation of treatment will help reduce both the short- and long-term neurodisabilities. A retrospective observational study was performed on children consecutively diagnosed with possible AE and then prospectively followed up in a single tertiary care children's hospital in Sri Lanka. Serum and cerebrospinal fluid were tested for neuroglial surface-binding autoantibodies using cell-based assays in majority of these children. Twenty-five children (mean age 7.6 years, standard deviation = 4) were recruited. In these children, presenting symptom was psychiatric in 11 children (44%), seizures in 10 (40%), language regression in 2 (8%), and combination of psychosis and convulsions in 2 (8%). Psychiatric presentations were more common in older (>6 years) compared with young children (p = 0.001), while neurological presentations were more common in children aged ≤6 years (p = 0.001). N-methyl-D-aspartate receptor (NMDAR) antibodies were detected in 9 (45%) and unspecified voltage-gated potassium channel antibodies in 1 (5%) of the 20 tested. All received intravenous steroids and immunoglobulins; 19 (76%) plasma exchange; 7 (29%) rituximab. Complete/substantial improvement at 3 months occurred in 64%. Pediatric Cerebral Performance Category score at last review was 1 (normal function for age) in 43%. Higher proportion of younger children required less intense therapy and had better recovery (56%). Death (8%), incomplete recovery (71%), and relapses (8%) were more in older children. Clinical presentation and disease outcomes were different in children aged <6 years compared with older age group. NMDAR antibody encephalitis was the commonest AE syndrome identified in this cohort.
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Affiliation(s)
- Jithangi Wanigasinghe
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - K. W. D. A. Anuradha
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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36
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Jan S, Anilkumar AC. Atypical Brain MRI Findings in a Child With Delayed Diagnosis of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Cureus 2021; 13:e18103. [PMID: 34692314 PMCID: PMC8525688 DOI: 10.7759/cureus.18103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/05/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is the most common cause of autoimmune encephalitis in children with a wide spectrum of clinical presentation and MRI findings. A high index of suspicion is required to avoid a delay in treatment and long-term morbidity. We present a healthy two-year-old male who developed fever and viral prodrome symptoms that rapidly progressed to acute encephalopathy, status epilepticus, quadriparesis, and abnormal movements. Brain MRI showed symmetric involvement of bilateral insula, posterior part of basal ganglia, and thalami. The patient survived the acute phase with supportive therapy but ended up with a devastating neurologic sequela, including developmental delay, inability to communicate, dysphagia, quadriparesis, and cortical visual impairment. Anti-N-methyl-D-aspartate (anti-NMDA) immunoglobulin G (IgG) antibodies were negative in serum and cerebrospinal fluid (CSF). The patient underwent an extensive inflammatory, infectious, metabolic, and genetic workup, including a whole-exome sequence (WES) and mitochondrial panel, which was unremarkable. CSF studies were unremarkable. Repeated anti-NMDA IgG antibodies were positive in serum a year after the presentation. This presentation highlights the crucial role of early immunotherapy in suspected autoimmune encephalitis (AE) cases, even at a young age, to prevent devastating neurologic outcomes. Moreover, clinicians should not rely on antibody results to treat a suspected case of AE due to possible false-negative test results, and the majority of AE cases remain without known antibodies.
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Affiliation(s)
- Saber Jan
- Pediatrics, State University of New York Upstate Medical University, Syracuse, USA
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37
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Tarantino S, Averna R, Ruscitto C, Ursitti F, Ferilli MAN, Moavero R, Papetti L, Proietti Checchi M, Sforza G, Balestri M, Grimaldi Capitello T, Vigevano F, Vicari S, Valeriani M. Neuropsychological Sequelae, Quality of Life and Adaptive Behavior in Children and Adolescents with Anti-NMDAR Encephalitis: A Narrative Review. Brain Sci 2021; 11:brainsci11111387. [PMID: 34827386 PMCID: PMC8615663 DOI: 10.3390/brainsci11111387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune illness characterized by a constellation of often severe, but treatable, psychiatric and neurological symptoms. Whereas symptoms such as psychosis and bizarre and abnormal motor behavior are common in adults, pediatric patients typically present with behavioral changes, irritability and sleep dysfunction. The recovery phase is usually slow and may be associated with longstanding adaptive, behavioral and neuropsychological problems. Very few studies explored the cognitive and adaptive sequelae in children with anti-NMDAR encephalitis. The present review article suggests that, although most children and adolescents return to their daily life and previous activities, they may have a low quality of life and show neuropsychological sequelae involving language, memory, especially verbal memory, and attentional resources, even after several months from the hospital discharge. In particular, the available results reveal difficulties in cognitive skills involving executive functions. This impairment is considered the “core” of the cognitive profile of young patients with anti-NMDAR encephalitis. On the other hand, some cognitive skills, such as general intelligence, show good overall recovery over time. Additional neuropsychological research evaluating larger samples, more homogenous methods and longitudinal studies is required.
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Affiliation(s)
- Samuela Tarantino
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
- Correspondence:
| | - Roberto Averna
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Claudia Ruscitto
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
| | - Fabiana Ursitti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Michela Ada Noris Ferilli
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Laura Papetti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Proietti Checchi
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Giorgia Sforza
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Balestri
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Teresa Grimaldi Capitello
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Federico Vigevano
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Stefano Vicari
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Massimiliano Valeriani
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
- Center for Sensory-Motor Interaction, Denmark Neurology Unit, Aalborg University, 9100 Aalborg, Denmark
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Tanguturi YC, Hanzlik E, Pagano L, Cundiff AW, Graham TB, Fuchs DC. Anti-NMDAR Encephalitis: Multidisciplinary Development of a Clinical Practice Guideline. Hosp Pediatr 2021; 11:1295-1302. [PMID: 34642216 DOI: 10.1542/hpeds.2021-005882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Yasas C Tanguturi
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences
| | | | | | - Allyson Witters Cundiff
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences
| | | | - D Catherine Fuchs
- Division of Child and Adolescent Psychiatry, Departments of Psychiatry and Behavioral Sciences and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Kennedy C, O'Shea R, De Ranieri D. Physical Therapy Interventions and Outcome Measures for a Patient Diagnosed with Anti-NMDA Receptor Encephalitis. Pediatr Ann 2021; 50:e437-e443. [PMID: 34617842 DOI: 10.3928/19382359-20210917-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common cause of autoimmune encephalitis after acute demyelinating encephalitis. Patients usually present with acute behavioral changes, psychosis, and abnormal limb movements and can also present with symptoms of catatonia. Treatment typically consists of an immunotherapy protocol consisting of intravenous immunoglobulin, corticosteroids, and plasmapheresis. This article describes the medical treatment, physical therapy (PT) interventions, and outcomes of a 16-year-old patient with anti-NMDA receptor encephalitis with malignant catatonia. Using PT interventions such as bed mobility, transfer, and gait training, and parent education initially, and progressing to balance re-education and age-appropriate functional tasks the patient was able to progress and be discharged to home with family with a recommendation for continued PT treatment in the outpatient setting. [Pediatr Ann. 2021;50(10):e437-e443.].
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40
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Manglani M, Poley M, Kumar A, McSherry G, Ericson JE. Anti-NMDAR Encephalitis After Neonatal HSV-1 Infection in a Child With Low TLR-3 Function. Pediatrics 2021; 148:peds.2020-035824. [PMID: 34385350 DOI: 10.1542/peds.2020-035824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 11/24/2022] Open
Abstract
Neonatal herpes simplex virus encephalitis (HSVE) often results in long-lasting neuro-disability in affected children. In addition to primary HSVE and HSVE relapses, children with herpes simplex virus are at increased risk of developing anti-N-methyl-d-aspartate receptor encephalitis (NMDARe), an autoimmune encephalitis. In this study, we describe a patient with neonatal disseminated herpes infection, who developed HSVE after discontinuation of 2 years of acyclovir suppressive therapy. After resolution of HSVE, the patient rapidly deteriorated with significant behavioral and neurologic changes including emotional outbursts, fearfulness, involuntary movements, and focal seizures. The patient was diagnosed with anti-NMDARe and was later found to have low toll-like receptor-3 function. In this study, we review published pediatric cases of anti-NMDARe after HSVE as well as previous literature and primary data examining the presentation, predisposing risk factors, predictive outcomes, future directions, and the role of immunodeficiency in HSVE-mediated anti-NMDARe. The neonatal immune system and developing brain are disproportionately vulnerable to early viral exposure; therefore, it is important to recognize the value of early immunodeficiency screening in patients with neonatal herpes simplex virus. By understanding the immune landscape within this patient population, we can mitigate long-term neurologic disability and improve the quality of life of affected children.
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Affiliation(s)
- Monica Manglani
- College of Medicine, Pennsylvania State, Hershey, Pennsylvania.,Medical Scientist Training Program
| | - Marian Poley
- Departments of Medicine and Pediatrics, University of Maryland Medical Center, Baltimore, Maryland
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Wilkinson-Smith A, Blackwell LS, Howarth RA. Neuropsychological outcomes in children and adolescents following anti-NMDA receptor encephalitis. Child Neuropsychol 2021; 28:212-223. [PMID: 34435553 DOI: 10.1080/09297049.2021.1965110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anti-N-methyl-d-aspartate receptor encephalitis (ANMDARE) is a neurologic disorder that is becoming more recognized in children and adolescents. Early studies suggested that patients typically recover well, but more recent data suggests that children may experience persistent cognitive deficits, especially in verbal memory and executive functioning. The aims of this study are to evaluate areas of impairment and to characterize neuropsychological outcomes in pediatric patients with ANMDARE. This was a multi-centered retrospective chart review. We identified 23 pediatric patients who were, on average, 18.5 months from diagnosis. Patients underwent comprehensive neuropsychological assessment, including measures of intellectual functioning, memory, reading, verbal fluency, visuomotor skills, attention, and working memory. Caregiver ratings and information regarding resource utilization were also collected (e.g., formal school services, outpatient rehabilitation, psychological support). Neuropsychological impairment index (NPI) scores were calculated for each patient. Neuropsychological outcomes highlighted variability across individuals. Memory and fine motor dexterity were particularly impacted. Almost 90% of caregivers reported more concerns than average on at least one measure of emotional-behavioral, adaptive, or executive functioning. More than two-thirds of the sample were considered impaired based on NPI scores on performance measures. More than three quarters of the sample received outpatient intervention, most often consisting of school-based services. Our findings provide additional quantitative evidence that pediatric patients recovering from ANMDARE demonstrate ongoing cognitive concerns. While most patients experience remarkable recoveries following appropriate diagnosis and treatment, ongoing monitoring and support is recommended over time for these patients.
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Affiliation(s)
- Alison Wilkinson-Smith
- Department of Psychological Services, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laura S Blackwell
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Robyn A Howarth
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
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42
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Hansen MA, Hasbun R. US Hospitalizations and 60-Day Readmission Rates Associated with Herpes simplex virus Encephalitis: Analysis of All Cause Readmissions and Encephalopathy Associated Readmissions. Clin Infect Dis 2021; 74:1174-1182. [PMID: 34240104 DOI: 10.1093/cid/ciab613] [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: 05/06/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is the most common cause of encephalitis hospitalizations. We sought to describe and analyze features associated with all cause readmissions and encephalopathy associated readmissions amongst HSE cases. METHODS HSE hospitalizations and 60-day rehospitalizations were assessed in a retrospective cohort using linked hospitalizations from the Healthcare Utilization Project (HCUP) National Readmission Database (NRD) from 2010 through 2017. Risk factors for all-cause readmissions and encephalopathy associated readmissions were assessed with a weighted logistic regression model. RESULTS There were 10,272 HSE cases in the US between 2010 and 2017, resulting in a national rate of 4.95 per 100,000 hospitalizations. A total of 23.7% were readmitted at least once within 60-days. Patients that were readmitted were older (mean age 62.4 vs. 57.9, p<0.001), had a greater number of procedures at the index hospitalization (aOR 1.03, p<0.001) and have a higher Charlson comorbidity score (aOR 1.11, p<0.001). Amongst those readmitted, 465 (16.5%) had an encephalopathy related diagnosis. Over eight years, the rate of encephalopathy associated readmissions increased from 0.12 to 0.20. Encephalopathy specific readmissions were found to be associated with greater age (mean age 65.9 vs. 61.7, p = 0.004) and findings of cerebral edema at index hospitalization (aOR 2.16, p <0.001). CONCLUSIONS HSE readmissions are relatively common, particularly among older and sicker individuals. However, early signs and symptoms of neurological disease at index were correlated with encephalopathic specific readmissions.
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Affiliation(s)
- Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Rodrigo Hasbun
- Division of Infectious Disease, Department of Internal Medicine, UT Health McGovern Medical School, Houston, TX
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Li Q, Fu N, Han Y, Qin J. Pediatric Autoimmune Encephalitis and Its Relationship With Infection. Pediatr Neurol 2021; 120:27-32. [PMID: 33964702 DOI: 10.1016/j.pediatrneurol.2021.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/31/2022]
Abstract
Autoimmune encephalitis (AE) is an increasingly recognized inflammatory disorder of the central nervous system and is most often characterized by antibodies against intracellular and neuronal surface antigens. AE is a devastating disease that may result in developmental delay or regression in children. However, the pathogenesis of AE is not clear, and immune system disorders after infection likely play an important role in AE. Many studies have reported that patients with herpes simplex virus encephalitis develop anti-N-methyl-d-aspartate receptor encephalitis after antiviral treatment. It is critical to recognize pediatric AE early and to distinguish it from infectious forms because AE is treatable and responsive to immunotherapies. In this review, we discuss the clinical features of pediatric AE and focus on the relationship between AE and postinfection status. In addition, we review the probable mechanisms underlying infection-triggered AE, which include molecular mimicry, bystander activation, epitope spreading, immune system disorder, and genetic susceptibility.
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Affiliation(s)
- Qinrui Li
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Na Fu
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China
| | - Ying Han
- Department of Pediatrics, Peking University First Hospital, Beijing, P.R. China.
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, P.R. China.
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44
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Goenka A, Chikkannaiah M, Kumar G. Pediatric auto-immune encephalitis. Curr Probl Pediatr Adolesc Health Care 2021; 51:101031. [PMID: 34272178 DOI: 10.1016/j.cppeds.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pediatric Auto-Immune Encephalitis (PAE) is a neuro-inflammatory disorder with a varied presentation. The discovery of the Anti NMDA receptor and other antibodies as the causative agents of PAE, has led to an increased need for guidelines for diagnosis and management of these disorders. PAE remains a challenging group of disorders due to their varying presentations and etiology with a prolonged clinical course. The wide spectrum of clinical symptoms involves altered mental status, movement disorders, acute behavioral changes, psychosis, delirium, seizures, and insomnia. This group of disorders was recently recognized in the children. This review provides clinicians with information on the most common PAE disorders, the spectrum of their clinical presentation, diagnostic tests and treatment protocols based on the current literature.
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Affiliation(s)
- Ajay Goenka
- Dayton Children Hospital, Wright State University Boonshoft School of Medicine, 1 Children Plaza, Dayton Ohio 45404.
| | - Mahesh Chikkannaiah
- Dayton Children Hospital, Wright State University Boonshoft School of Medicine, 1 Children Plaza, Dayton Ohio 45404.
| | - Gogi Kumar
- Dayton Children Hospital, Wright State University Boonshoft School of Medicine, 1 Children Plaza, Dayton Ohio 45404.
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45
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Adams AV, Van Mater H, Gallentine W, Mooneyham GC. Psychiatric Phenotypes of Pediatric Patients With Seropositive Autoimmune Encephalitis. Hosp Pediatr 2021; 11:743-750. [PMID: 34103402 DOI: 10.1542/hpeds.2020-005298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Patients with autoimmune encephalitis (AE) often present with symptoms that are broadly characterized as psychiatric or behavioral, yet little attention is given to the precise symptomatology observed. We sought to more fully define the psychiatric symptoms observed in patients with anti-N-methyl-D-aspartate receptor (NMDAR), anti-glutamic-acid-decarboxylase 65 (GAD65), and anti-voltage-gated-potassium-channel complex (VGKC) antibody-mediated AE using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition nomenclature. METHODS We present a case series (n = 25) using a retrospective chart review of 225 patients evaluated for AE in a tertiary care academic medical center between 2014 and 2018. The included patients were ≤18 years old with anti-NMDAR AE (n = 13), anti-GAD65 AE (n = 7), or anti-VGKC AE (n = 5). The frequency of neuropsychiatric symptoms present at the onset of illness and time to diagnosis were compared across groups. RESULTS Psychiatric symptoms were seen in 92% of patients in our cohort. Depressive features (72%), personality change (64%), psychosis (48%), and catatonia (32%) were the most common psychiatric symptoms exhibited. On average, patients experienced impairment in ≥4 of 7 symptom domains. No patients had isolated psychiatric symptoms. The average times to diagnosis were 1.7, 15.5, and 12.4 months for anti-NMDAR AE, anti-GAD65 AE, and anti-VGKC AE, respectively (P < .001). CONCLUSIONS The psychiatric phenotype of AE in children is highly heterogenous. Involving psychiatry consultation services can be helpful in differentiating features of psychosis and catatonia, which may otherwise be misidentified. Patients presenting with psychiatric symptoms along with impairments in other domains should prompt a workup for AE, including testing for all known antineuronal antibodies.
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Affiliation(s)
- Ashley V Adams
- Department of Pediatrics, The Warren Alpert Medical School, Brown University, Providence, Rhode Island .,School of Medicine, Duke University, Durham, North Carolina
| | | | - William Gallentine
- Department of Pediatrics, Stanford Medicine, Stanford University, Stanford, California
| | - GenaLynne C Mooneyham
- School of Medicine, Duke University, Durham, North Carolina.,Departments of Pediatrics.,Psychiatry and Behavioral Sciences
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46
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Kawano G, Yokochi T, Nishikomori R, Watanabe Y, Ohbu K, Takahashi Y, Shintaku H, Matsuishi T. Case Report: Rituximab Improved Epileptic Spasms and EEG Abnormalities in an Infant With West Syndrome and Anti-NMDAR Encephalitis Associated With APECED. Front Neurol 2021; 12:679164. [PMID: 34093423 PMCID: PMC8176955 DOI: 10.3389/fneur.2021.679164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/26/2021] [Indexed: 01/18/2023] Open
Abstract
Background: Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy is a rare autosomal recessive disorder caused by a mutation in the autoimmune regulator gene. Patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy typically exhibit hypoparathyroidism, adrenocortical failure, and chronic mucocutaneous candidiasis. There are only a few case reports of autoimmune encephalitis during autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy, but not as an initial manifestation. Furthermore, there are no reports of patients with infantile spasms/West syndrome with autoimmune encephalitis, partly because the median age for paediatric patients with anti-N-methyl-D-aspartate receptor encephalitis, which is the most frequent and best characterised in paediatric autoimmune encephalitides, is 13–14 years. Herein, we present a case of a 3-month-old infant with autoimmune encephalitis as an initial manifestation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy who later developed infantile spasms/West syndrome. Case Presentation: A 3-month-old girl was admitted to our hospital with a fever, involuntary movements in all four limbs, and right-side facial palsy. Acute central nervous system demyelination diseases were suspected from neuroimaging findings and the presence of the cerebrospinal fluid oligoclonal band. She did not respond to multiple methylprednisolone pulse therapies and later developed infantile spasms/West syndrome and diabetes mellitus. Rituximab, a chimeric mouse/human monoclonal antibody directed against human CD20 which depletes B cells, was initially administered as a treatment for autoimmune encephalitis. Unexpectedly, this treatment resulted in complete spasm cessation and resolution of hypsarrhythmia. The patient eventually showed severely delayed developmental milestones, and her electroencephalography findings showed periodic generalised slow spike-and-wave pattern. Conclusions: Despite the limited ability to extrapolate findings from a single case, rituximab's effects may suggest that B cells play a crucial role in infantile spasms/West syndrome mechanisms; use of rituximab as an aetiology-specific treatment for infantile spasms/West syndrome patients with autoimmune encephalitis or its effectiveness for infantile spasms/West syndrome patients with other underlying mechanisms warrants further investigation.
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Affiliation(s)
- Go Kawano
- Department of Paediatrics, St Mary's Hospital, Kurume, Fukuoka, Japan
| | - Takaoki Yokochi
- Department of Paediatrics, St Mary's Hospital, Kurume, Fukuoka, Japan
| | - Ryuta Nishikomori
- Department of Paediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yoriko Watanabe
- Department of Paediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Keizo Ohbu
- Department of Paediatrics, St Mary's Hospital, Kurume, Fukuoka, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Centre, National Hospital Organization (NHO) Shizuoka Institute of Epilepsy and Neurological Disorder, Shizuoka, Japan
| | - Haruo Shintaku
- Department of Paediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toyojiro Matsuishi
- Department of Paediatrics, St Mary's Hospital, Kurume, Fukuoka, Japan.,Research Centre for Children and Research Centre for Rett Syndrome, St Mary's Hospital, Kurume, Fukuoka, Japan.,Division of Gene Therapy and Regenerative Medicine, Cognitive and Molecular Research Institute of Brain Diseases, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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47
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Matera E, Gabellone A, Petruzzelli MG, Marzulli L, Furente F, Margari L. Anti-N-Methyl-D-Aspartate Receptor Encephalitis with Serum Anti-Thyroid Antibodies: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931104. [PMID: 33999913 PMCID: PMC8141336 DOI: 10.12659/ajcr.931104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anti-N methyl D-aspartate receptor encephalitis (anti-NMDArE) is a disorder in which triggers such as infectious agents or neoplastic disease can lead to an autoimmune response against the nervous system, although this disorder is usually idiopathic. Some patients with anti-NMDArE have evidence of other autoimmune alterations. Here, we present a case of non-paraneoplastic anti-NMDArE with elevation of serum anti-thyroid antibodies and a literature review of this association. CASE REPORT A 16-year-old girl was admitted in the University Hospital of Bari for a new onset of tonic-clonic seizures. Progressively, the patient manifested also psychomotor agitation, language difficulties, memory impairment, psychotic symptoms, autonomic dysfunction, and psychomotor retardation. Blood evaluation revealed the presence of anti-thyroglobulin, anti-thyroperoxidase, and anti-NMDAr antibodies. Cerebrospinal fluid analysis confirmed the diagnosis of anti-NMDArE. No tumors were found. Treatment with intravenous immunoglobulin, steroids, and plasma exchange relieved symptoms and decreased levels of serum anti-NMDAr antibodies. After 12 months, the patient had full recovery of communicative capacity, with the persistence of slight difficulty of memory and mild tendency to irritability. Blood exams shown persistence of anti-NMDAr positivity and absence of anti-thyroid antibodies. CONCLUSIONS We report a rare case in which an autoimmune involvement of thyroid gland was concurrent with an anti-NMDArE. It would be useful for clinical practice to clarify whether the presence of anti-thyroid antibody an characterize the clinical course, prognosis, and response to treatment of the idiopathic type of anti-NMDArE.
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Affiliation(s)
- Emilia Matera
- Department of Biomedical Sciences and Human Oncology, University Hospital of Bari, Bari, Italy
| | - Alessandra Gabellone
- Department of Biomedical Sciences and Human Oncology, University Hospital of Bari, Bari, Italy
| | | | - Lucia Marzulli
- Department of Biomedical Sciences and Human Oncology, University Hospital of Bari, Bari, Italy
| | - Flora Furente
- Department of Biomedical Sciences and Human Oncology, University Hospital of Bari, Bari, Italy
| | - Lucia Margari
- Department of Biomedical Sciences and Human Oncology, University Hospital of Bari, Bari, Italy
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48
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Heng KYC, Lee JH, Thomas T. Anti-N-Methyl-D-aspartate receptor encephalitis masquerading as fever of unknown origin. Clin Case Rep 2021; 9:2323-2327. [PMID: 33936687 PMCID: PMC8077294 DOI: 10.1002/ccr3.4025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/05/2020] [Accepted: 01/24/2021] [Indexed: 11/24/2022] Open
Abstract
Fever of unknown origin (FUO) is a diagnostic challenge. Anti-N-methyl-D-aspartate receptor encephalitis should be considered in children with FUO and new-onset neurological symptoms without significant encephalopathy.
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Affiliation(s)
- Katrina Yi Ching Heng
- Department of Child DevelopmentDepartment of Paediatric MedicineKK Women's and Children's HospitalSingapore CitySingapore
| | - Jan Hau Lee
- Department of Children's Intensive Care UnitDepartment of Paediatric SubspecialtiesKK Women's and Children's HospitalSingapore CitySingapore
| | - Terrence Thomas
- Paediatric Neurology ServiceDepartment of Paediatric MedicineKK Women's and Children's HospitalSingapore CitySingapore
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49
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Moise AM, Karakis I, Herlopian A, Dhakar M, Hirsch LJ, Cotsonis G, LaRoche S, Cabrera Kang CM, Westover B, Rodriguez A. Continuous EEG Findings in Autoimmune Encephalitis. J Clin Neurophysiol 2021; 38:124-129. [PMID: 31800465 PMCID: PMC7263965 DOI: 10.1097/wnp.0000000000000654] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Autoimmune encephalitis (AE) is a cause of new-onset seizures, including new-onset refractory status epilepticus, yet there have been few studies assessing the EEG signature of AE. METHODS Multicenter retrospective review of patients diagnosed with AE who underwent continuous EEG monitoring. RESULTS We identified 64 patients (male, 39%; white, 49%; median age, 44 years); of whom, 43 (67%) were antibody-proven AE patients. Of the patients with confirmed antibody AE, the following were identified: N-methyl-D-aspartate receptor (n = 17, 27%), voltage-gated potassium channel (n = 16, 25%), glutamic acid decarboxylase (n = 6, 9%), and other (n = 4, 6%). The remaining patients were classified as probable antibody-negative AE (n = 11, 17%), definite limbic encephalitis (antibody-negative) (n = 2, 3%), and Hashimoto encephalopathy (n = 8, 13%). Fifty-three percent exhibited electrographic seizures. New-onset refractory status epilepticus was identified in 19% of patients. Sixty-three percent had periodic or rhythmic patterns; of which, 38% had plus modifiers. Generalized rhythmic delta activity was identified in 33% of patients. Generalized rhythmic delta activity and generalized rhythmic delta activity plus fast activity were more common in anti-N-methyl-D-aspartate AE (P = 0.0001 and 0.0003, respectively). No other periodic or rhythmic patterns exhibited AE subtype association. Forty-two percent had good outcome on discharge. Periodic or rhythmic patterns, seizures, and new-onset refractory status epilepticus conferred an increased risk of poor outcome (OR, 6.4; P = 0.0012; OR, 3; P = 0.0372; OR, 12.3; P = 0.02, respectively). CONCLUSION Our study confirms a signature EEG pattern in anti-N-methyl-D-aspartate AE, termed extreme delta brush, identified as generalized rhythmic delta activity plus fast activity in our study. We found no other pattern association with other AE subtypes. We also found a high incidence of seizures among patients with AE. Finally, periodic or rhythmic patterns, seizures, and new-onset refractory status epilepticus conferred an increased risk of poor outcome regardless of AE subtype.
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Affiliation(s)
- Anna-Marieta Moise
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
- Mission Neurosciences Program, Epilepsy Department, Mission Health, Asheville, North Carolina, U.S.A
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Aline Herlopian
- Department of Neurology and Yale Comprehensive Epilepsy Center, Yale University, New Haven, Connecticut, U.S.A
| | - Monica Dhakar
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Lawrence J. Hirsch
- Department of Neurology and Yale Comprehensive Epilepsy Center, Yale University, New Haven, Connecticut, U.S.A
| | - George Cotsonis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Suzette LaRoche
- Mission Neurosciences Program, Epilepsy Department, Mission Health, Asheville, North Carolina, U.S.A
| | | | - Brandon Westover
- MGH Epilepsy Service and Division of Clinical Neurophysiology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Andres Rodriguez
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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50
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Gong X, Chen C, Liu X, Lin J, Li A, Guo K, Zhou D, Hong Z. Long-term Functional Outcomes and Relapse of Anti-NMDA Receptor Encephalitis: A Cohort Study in Western China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e958. [PMID: 33589542 PMCID: PMC8105891 DOI: 10.1212/nxi.0000000000000958] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/03/2020] [Indexed: 02/05/2023]
Abstract
Objective To study the factors associated with relapse and functional outcomes in patients with anti-NMDA receptor encephalitis in Western China. Methods The Outcome of the anti-NMDA receptor Encephalitis Study in Western China was initiated in October 2011 to collect prospective observational data from consecutively enrolled patients with anti-NMDA receptor encephalitis. Results We consecutively enrolled 244 patients (median age: 26 years, range: 9–78 years; females: 128 [52.45%]) between October 2011 and September 2019. Fatality occurred in 17 (6.96%) patients, and tumors were found in 38 (15.57%) patients. The median follow-up duration was 40 (6–96) months. Of these patients, 84.8% showed clinical improvements within 4 weeks after immunotherapy, with a median modified Rankin Scale of 2 (interquartile range [IQR]: 2–3), and 80.7% (median: 1, IQR: 0–2) and 85.7% (median: 0, IQR: 0–1) had substantial recovery (i.e., mild or no residual symptoms) at 12 and 24 months, respectively. The overall prognosis was still improving at 42 months after onset. Disturbance of consciousness during the first month was the only independent predictor (OR: 2.91, 95% CI: 1.27–6.65; p = 0.01) of a poor functional neurologic outcome. Overall, 15.9% of the patients had one or multiple relapses, with 82.0% experiencing the first relapse within 24 months and 76.9% experiencing relapses that were less severe than the initial episodes. Relapse-related risk factors included the female sex and delayed treatment (p < 0.05). Conclusions Most patients achieved favorable long-term functional outcomes. Some patients experienced one or multiple relapses, especially female patients. Timely immunotherapy at onset may reduce the risk of relapse.
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Affiliation(s)
- Xue Gong
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China
| | - Chu Chen
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China
| | - Xu Liu
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China
| | - Jingfang Lin
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China
| | - Aiqing Li
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China.
| | - Kundian Guo
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China
| | - Dong Zhou
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China.
| | - Zhen Hong
- From the Department of Neurology (X.G., C.C., X.L., J.L., A.L., K.G., D.Z., Z.H.), West China Hospital, Sichuan University, Chengdu; and Department of Neurology (Z.H.), Chengdu Shangjin Nanfu Hospital, Sichuan, China.
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