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Kanekar S, Zacharia T, Agarwal A. Neoplastic Meningitis and Paraneoplastic Syndromes. Radiol Clin North Am 2021; 59:409-423. [PMID: 33926686 DOI: 10.1016/j.rcl.2021.01.007] [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] [Indexed: 11/18/2022]
Abstract
Neoplastic meningitis (NM) and paraneoplastic syndromes (PNSs) are a rare group of disorders present in patients with cancer. Clinical diagnosis of these conditions is challenging, and imaging and laboratory analysis play a significant role in diagnosing. Diagnosis of NM largely depends on documenting circulating tumor cells in the cerebrospinal fluid (CSF) and/or leptomeningeal and nodular enhancement on contrast-enhanced MR imaging of the brain or axial spine. PNSs encompass a variety of symptoms or syndromes. Paraneoplastic neuronal disorder diagnosis requires a multidimensional approach, high clinical suspicion, CSF and serum examination, and imaging. Neuroimaging is an integral part in the evaluation.
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Affiliation(s)
- Sangam Kanekar
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA; Department of Neurology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA.
| | - Thomas Zacharia
- Department of Radiology, Penn State Health, Mail Code H066, 500 University drive, Hershey, PA 17033, USA
| | - Amit Agarwal
- Department of Radiology, UT Southwestern Medical School and Parkland Hospital, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Abdul Rashid AM, Mohamad Mokhtar E, Md Noh MSF. A case of anti- N-methyl-d-aspartate receptor encephalitis. SAGE Open Med Case Rep 2020; 8:2050313X20926431. [PMID: 32547761 PMCID: PMC7273584 DOI: 10.1177/2050313x20926431] [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: 07/18/2019] [Accepted: 04/20/2020] [Indexed: 11/19/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor encephalitis is
characterized by the clinical manifestation of neuropsychiatric symptoms, predominantly
affecting young adults, and frequently associated with neoplasms. It is the second most
common cause of autoimmune and paraneoplastic encephalitis. Early diagnosis is often
missed, as patients are commonly diagnosed with psychiatric illnesses and are treated with
antipsychotics – which rarely gives complete resolution of symptoms. Herein, we discuss a
patient with mixed clinical, imaging, electroencephalogram, and laboratory findings, with
an eventual diagnosis of anti-N-methyl-d-aspartate receptor
encephalitis requiring immunotherapy and operative intervention.
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Affiliation(s)
- Anna Misyail Abdul Rashid
- Department of Medicine, Level 3, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | | | - Mohamad Syafeeq Faeez Md Noh
- Department of Imaging, Level 3, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
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Early identification of anti-NMDA receptor encephalitis presenting cerebral lesions in unconventional locations on magnetic resonance imaging. J Neuroimmunol 2018; 320:101-106. [DOI: 10.1016/j.jneuroim.2018.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/25/2018] [Accepted: 03/25/2018] [Indexed: 11/24/2022]
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Ho ACC, Chan SHS, Chan E, Wong SSN, Fung STH, Cherk SWW, Fung ELW, Ma KH, Tsui KW, Yau EKC, Wong VCN. Anti-N-methyl-d-aspartate receptor encephalitis in children: Incidence and experience in Hong Kong. Brain Dev 2018; 40:473-479. [PMID: 29599011 DOI: 10.1016/j.braindev.2018.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/07/2018] [Accepted: 02/07/2018] [Indexed: 12/19/2022]
Abstract
AIM The study aims to analyze the incidence, clinical features, investigation findings and treatment outcomes of anti-N-methyl-d-aspartate receptor encephalitis in children from Hong Kong. METHOD A retrospective study was carried out on paediatric patients diagnosed with anti-NMDAR encephalitis in Hong Kong from January 2009 to December 2015. RESULTS Fifteen patients (67% female, 93% Chinese) were identified over seven years and the estimated incidence in Hong Kong was 2.2/million children per year (95% CI 1.2-3.6). The median age of presentation was 12 years (range 1-17 years). The most common symptom groups observed were abnormal psychiatric behavior or cognitive dysfunction (14/15, 93%) and seizures (14/15, 93%), followed by speech dysfunction (13/15, 87%), movement disorders (12/15, 80%), decreased level of consciousness (10/15, 67%) and autonomic dysfunction or central hypoventilation (5/15, 33%). The median number of symptom groups developed in each patient was 5 (range 3-6). All patients were treated with intravenous immunoglobulin and/or steroids. Three patients (20%) with more severe presentation required additional plasmapheresis and rituximab. Outcome was assessable in 14 patients. Among those eleven patients who had only received intravenous immunoglobulin and/or steroids, nine patients (82%) achieved full recovery. One patient (9%) had residual behavioral problem, while another one (9%) who developed anti-NMDAR encephalitis after herpes simplex virus encephalitis was complicated with dyskinetic cerebral palsy and epilepsy. Among those three patients who required plasmapheresis and rituximab, one (33%) had full recovery and two (66%) had substantial recovery. The median duration of follow up was 20.5 months (range 3-84 months). CONCLUSION Anti-NMDAR encephalitis is an acquired, severe, but potentially treatable disorder. Ethnicity may play a role in the incidence of anti-NMDAR encephalitis and we have provided a local incidence with the majority of patients being Chinese. The diagnosis of anti-NMDAR encephalitis should be considered in children presenting with a constellation of symptoms including psychiatric and neurological manifestations. Patients may respond to first line immunotherapy. For those who do not, second line therapy is indicated in order to achieve a better outcome.
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Affiliation(s)
- Alvin Chi-Chung Ho
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Sophelia Hoi-Shan Chan
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Eric Chan
- Division of Clinical Immunology, Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong
| | - Sheila Suet-Na Wong
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong
| | | | | | | | - Kam-Hung Ma
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Kwing-Wan Tsui
- Department of Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Eric Kin-Cheong Yau
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Virginia Chun-Nei Wong
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Bakpa OD, Reuber M, Irani SR. Antibody-associated epilepsies: Clinical features, evidence for immunotherapies and future research questions. Seizure 2016; 41:26-41. [PMID: 27450643 PMCID: PMC5042290 DOI: 10.1016/j.seizure.2016.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The growing recognition of epilepsies and encephalopathies associated with autoantibodies against surface neuronal proteins (LGI1, NMDAR, CASPR2, GABABR, and AMPAR) means that epileptologists are increasingly asking questions about mechanisms of antibody-mediated epileptogenesis, and about the use of immunotherapies. This review summarizes clinical and paraclinical observations related to autoimmune epilepsies, examines the current evidence for the effectiveness of immunotherapy, and makes epilepsy-specific recommendations for future research. METHOD Systematic literature search with summary and review of the identified publications. Studies describing the clinical characteristics of autoantibody-associated epilepsies and treatments are detailed in tables. RESULTS Literature describing the clinical manifestations and treatment of autoimmune epilepsies associated with neuronal cell-surface autoantibodies (NSAbs) is largely limited to retrospective case series. We systematically summarize the features of particular interest to epileptologists dividing patients into those with acute or subacute encephalopathies associated with epilepsy, and those with chronic epilepsy without encephalopathy. Available observational studies suggest that immunotherapies are effective in some clinical circumstances but outcome data collection methods require greater standardization. CONCLUSIONS The clinical experience captured suggests that clusters of clinical features associate well with specific NSAbs. Intensive and early immunotherapy is indicated when patients present with autoantibody-associated encephalopathies. It remains unclear how patients with chronic epilepsy and the same autoantibodies should be assessed and treated. Tables in this paper provide a comprehensive resource for systematic descriptions of both clinical features and treatments, and highlight limitations of current studies.
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Affiliation(s)
- Ochuko D Bakpa
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DS, UK.
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Abstract
Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune, often paraneoplastic disorder that presents with complex neuropsychiatric symptoms. It was first described in 2007 by Dalmau et al. Our patient presented with headache, behavioral changes and then seizures with hallucinations. She was initially misdiagnosed to have schizophrenia and was prescribed antipsychotics. She deteriorated and developed further seizures with hypoventilation and choreoathetosis. Her blood investigations were positive for mycoplasma IGM. Her CSF studies showed high white cell counts, predominantly lymphocytes, and high anti-NMDA-R titre. Her brain MRI scans showed high tbl2 and FLAIR intensities in the grey and white matter of the left cerebellar hemisphere suggestive of acute disseminated encephalomyelitis. She responded to treatment with antibiotics, multiple antiepileptics, steroids and needed five sessions of plasmapheresis. There was no underlying malignancy on repeated scanning of the abdomen. She needed around one year for full recovery with intensive rehabilitation. The objective of this paper was to highlight the occurrence of this fairly new, challenging, easily missed, not-so-rare form of encephalitis often occurring in the absence of fever.
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Affiliation(s)
- Ahood Almuslamani
- Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatima Mahmood
- Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
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DeSena AD, Greenberg BM, Graves D. Three phenotypes of anti-N-methyl-D-aspartate receptor antibody encephalitis in children: prevalence of symptoms and prognosis. Pediatr Neurol 2014; 51:542-9. [PMID: 25070939 DOI: 10.1016/j.pediatrneurol.2014.04.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate (NMDA) receptor antibody encephalitis is becoming an increasingly recognized cause of encephalopathy in individuals previously presumed to have viral encephalitis. Various manifestations of this disease include altered mental status, behavioral changes, seizures, and movement disorders. We have noted three distinct subtypes of this disease which appear to have differential responses to immunotherapies and differences in prognosis. METHODS AND PATIENTS We report eight patients observed at our children's hospital from 2009 through 2013 who appear to clearly fall into one of our three clinical categories. To find comparable articles reflecting this classification, we then performed a MEDLINE search of all articles involving the subject heading "anti-NMDA receptor encephalitis" or just the keyword phrase "NMDA encephalitis," and we found 162 articles to review. Twenty-two articles were eliminated due to basic science, and we were able to review 105 of the remaining articles, most of which were case reports or case series, although a few were larger reviews. For the sake of our review, we defined type 1 or "classic" anti-NMDA receptor antibody encephalitis as having a duration of <60 days and being characterized predominantly by a catatonic or stuporous state, type 2 or psychiatric-predominant anti-NMDA receptor antibody encephalitis as having no noteworthy catatonic or stuporous state in addition to the presence of predominantly behavioral and psychiatric symptoms, and type 3 or catatonia-predominant anti-NMDA receptor antibody encephalitis as having a duration of ≥60 days in a predominantly catatonic or stuporous state. RESULTS We note that the poorest responders, even to aggressive immunotherapies, are the patients with catatonia-persistent type anti-NMDA receptor antibody encephalitis, which has, as its hallmark, prolonged periods of severe encephalopathy. Patients with predominantly psychiatric symptoms, which we call the psychiatric-predominant anti-NMDA receptor antibody encephalitis, have had excellent responses to plasma exchange or other immunotherapies and appear to have the least residual deficits at follow-up. Patients with fairly equal representations of periods of altered mental status, behavioral problems, and movement disorders appear to have an intermediate prognosis and likely require early aggressive immunotherapy. CONCLUSIONS In our series, we discuss representative examples of these clinical subtypes and their associated outcomes, and we suggest that tracking these subtypes in future cases of anti-NMDA receptor antibody encephalitis might lead to better understanding and better risk stratification with regard to immunotherapy decisions.
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Affiliation(s)
- Allen D DeSena
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas
| | - Benjamin M Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas
| | - Donna Graves
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas.
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Anti-N-methyl-d-aspartate receptor encephalitis associated with ovarian teratoma: clinical presentation, diagnosis, treatment, and surgical management. Int Cancer Conf J 2013. [DOI: 10.1007/s13691-013-0102-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Abstract
We present a patient with multiple sclerosis, diagnosed at the age of 16.5, in whom mental and orientation disturbances, strange behaviour as well as bizarre dyskinesias of the face and extremities occurred at age 20. After several days, tonic-clonic status epilepticus developed. Head computed tomography showed no abnormalities. Lumbar puncture revealed a pleocytosis of 20/3, which became normal after treatment. Seizures were brought under control, but the psychiatric symptoms persisted; they subsided after a dozen or so weeks. Magnetic resonance of the head and cervical spinal cord did not show any new abnormalities. After another several months, all symptoms recurred. A wide range of laboratory tests, as well as positron emission tomography, did not reveal any abnormalities. Suspicion of autoimmune encephalitis led to a test for serum anti-NMDA-receptor antibodies that confirmed the diagnosis. After immunotherapy, our patient improved and was transferred for rehabilitation.
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Tarula E, Ramkissoon S, Pittock S, Sheen VL. Progressive mental status changes and seizures with fluid attenuated inversion recovery (FLAIR) hyperintensity on brain MRI. J Clin Neurosci 2012. [DOI: 10.1016/j.jocn.2011.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Autoantibodies associated with diseases of the CNS: new developments and future challenges. Lancet Neurol 2011; 10:759-72. [PMID: 21777830 DOI: 10.1016/s1474-4422(11)70096-5] [Citation(s) in RCA: 351] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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