1
|
Zhang J, Li Y, Liu L, Dai F, Peng Y, Ma Q, Li L, Hong Y, Liu A, Zhang X, Wang X, He J, Bu H, Guo Y, Jiang H, Cui S, Sun H, Wang J. Development of a short-term prognostic model for anti-N-methyl-D-aspartate receptor encephalitis in Chinese patients. BMC Neurol 2024; 24:276. [PMID: 39123191 PMCID: PMC11313159 DOI: 10.1186/s12883-024-03724-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 06/12/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Recognizing the predictors of poor short-term prognosis after first-line immunotherapy in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is essential for individualized treatment strategy. The objective of this study was to ascertain the factors that forecast short-term prognosis in patients with anti-NMDAR encephalitis, develop a prognostic prediction model, and authenticate its efficacy in an external validation cohort. Further, all patients were followed-up long-term to assess the factors of long-term outcome and relapses. METHODS A prospective enrollment of patients diagnosed with anti-NMDAR encephalitis was conducted across five clinical centers in China from June 2014 to Mar 2022. The enrolled patients were divided into the derivation and validation sets based on enrollment time. The short-term prognostic model was visualized using a nomogram. Further, all patients were followed-up long-term to assess the factors of long-term outcome. RESULTS This study found that poor short-term prognosis was a risk factor for poor long-term outcome (6-month prognosis, OR 29.792, 95%CI 6.507-136.398, p < 0.001; 12-month prognosis, OR 15.756, 95%CI 3.384-73.075, p < 0.001; 24-month prognosis, OR 5.500, 95%CI 1.045-28.955, p = 0.044). Abnormal behavior or cognitive dysfunction (OR 8.57, 95%CI 1.48-49.79, p = 0.017), consciousness impairment (OR19.32, 95%CI 3.03-123.09, p = 0.002), autonomic dysfunction or central hypoventilation (OR 5.66, 95%CI 1.25-25.75, p = 0.025), CSF pleocytosis (OR 4.33, 95%CI 1.48-12.65, p = 0.007), abnormal EEG (OR 5.48, 95% CI 1.09-27.54, p = 0.039) were independent predictors for a poor short-term prognosis after first-line immunotherapy. A nomogram that incorporated those factors showed good discrimination and calibration abilities. The area under the curve (AUC) for the prognostic model were 0.866 (95%CI: 0.798-0.934) with a sensitivity of 0.761 and specificity of 0.869. CONCLUSION We established and validated a prognostic model that can provide individual prediction of short-term prognosis after first-line immunotherapy for patients with anti-NMDAR encephalitis. This practical prognostic model may help neurologists to predict the short-term prognosis early and potentially assist in adjusting appropriate treatment timely.
Collapse
Affiliation(s)
- Jingxiao Zhang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yatong Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Feifei Dai
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yujing Peng
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qiuying Ma
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lin Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yu Hong
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinghu Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaohui Wang
- Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Junying He
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hui Bu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yanjun Guo
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hanqiu Jiang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shilei Cui
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Houliang Sun
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
2
|
Guo X, Yu J, Quan C, Xiao J, Wang J, Zhang B, Hao X, Wu X, Liang J. The effect of N-methyl-D-aspartate receptor antagonists on the mismatch negativity of event-related potentials and its regulatory factors: A systematic review and meta-analysis. J Psychiatr Res 2024; 172:210-220. [PMID: 38402843 DOI: 10.1016/j.jpsychires.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/28/2024] [Accepted: 02/01/2024] [Indexed: 02/27/2024]
Abstract
This study investigates the influence of N-methyl-D-aspartate receptor (NMDAR) antagonists on the mismatch negativity (MMN) components of event-related potentials (ERPs) in healthy subjects and explores whether NMDAR antagonists have different effects on MMN components under different types of antagonists, drug dosages, and deviant stimuli. We conducted a comprehensive literature search of PubMed, EMBASE, and the Cochrane Library from inception to August 1, 2023 for studies comparing the MMN components between the NMDAR antagonist intervention group and the control group (or baseline). All statistical analyses were performed using Stata version 12.0 software. Sixteen articles were included in the systematic review: 13 articles were included in the meta-analysis of MMN amplitudes, and seven articles were included in the meta-analysis of MMN latencies. The pooled analysis showed that NMDAR antagonists reduced MMN amplitudes [SMD (95% CI) = 0.32 (0.16, 0.47), P < 0.01, I2 = 47.3%, p < 0.01] and prolonged MMN latencies [SMD (95% CI) = 0.31 (0.13, 0.49), P = 0.16, I2 = 28.3%, p < 0.01]. The type of antagonist drug regulates the effect of NMDAR antagonists on MMN amplitudes. Different antagonists, doses of antagonists, and types of deviant stimuli can also have different effects on MMN. These findings indicate a correlation between NMDAR and MMN, which may provide a foundation for the application of ERP-MMN in the early identification of NMDAR encephalitis.
Collapse
Affiliation(s)
- Xin Guo
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Jieyang Yu
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Chunhua Quan
- Central Laboratory, The Affiliated Hospital of Yanbian University, Juzi-St., No.1327, Yanji, 133000, China.
| | - Jinyu Xiao
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Jiangtao Wang
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Bo Zhang
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Xiaosheng Hao
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Xuemei Wu
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| | - Jianmin Liang
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Pediatric Neurology, Changchun, 130021, China.
| |
Collapse
|
3
|
Hou C, Li X, Zeng Y, Gao Y, Wu W, Zhu H, Zhang Y, Wu W, Tian Y, Zheng K, Chen L, Peng B, Chen WX. Brain magnetic resonance imaging as predictors in pediatric anti-N-methyl-D-aspartate receptor encephalitis. Mult Scler Relat Disord 2024; 82:105061. [PMID: 38134605 DOI: 10.1016/j.msard.2023.105061] [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: 03/29/2023] [Revised: 09/26/2023] [Accepted: 10/08/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To investigate the associations between brain magnetic resonance imaging (MRI) changes and clinical profiles in children with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHODS Clinical data and brain MRI results of children diagnosed with anti-NMDAR encephalitis in Guangzhou Women and Children's Medical Center from October 2014 to June 2022 were retrospectively studied. RESULTS A total of 143 children (Male: female 54:89) were enrolled, with a mean onset age of 6.8 years (6.8 ± 3.1). 40.6 % (58/143) of patients had abnormal initial brain MRI. Lesions in temporal lobe (34.5 %, 20/58) and frontal lobe (25.9 %, 15/58) were relatively common. Children with abnormal initial brain MRI were prone to have fever (P = 0.023), dystonia (P = 0.037), positive MOG antibodies (P = 0.015), higher cerebrospinal fluid (CSF) white blood cell count (WBC) (P = 0.019) and to receive rituximab treatment (P = 0.037). There were no significant differences in modified Rankin Scale (mRS) scores before immunotherapy, after immunotherapy and at last follow-up between the normal initial brain MRI group and abnormal group. No initial brain MRI changes were found to be associated with relapses. Brain MRI was reviewed in 72 patients at last follow-up with a median follow-up time of 25.5 months and 48.6 % (35/72) of patients had abnormal brain MRI. The mRS score of the group with normal brain MRI at last follow-up was significantly lower than that of the abnormal group. CONCLUSIONS About 40.0 % of children with anti-NMDAR encephalitis had abnormal initial brain MRI. Initial brain MRI was associated with certain clinical profiles, but not with relapse and prognosis. Around half of patients had abnormal brain MRI at last follow-up and were prone to have higher mRS score.
Collapse
Affiliation(s)
- Chi Hou
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Xiaojing Li
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yiru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yuanyuan Gao
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenxiao Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Haixia Zhu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yani Zhang
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wenlin Wu
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Yang Tian
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Kelu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Liangfeng Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Bingwei Peng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China
| | - Wen-Xiong Chen
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jin Sui Road, Guangzhou, Guangdong Province 510623, PR China.
| |
Collapse
|
4
|
Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Autoimmune Encephalitis. J Clin Neurol 2024; 20:3-22. [PMID: 38179628 PMCID: PMC10782092 DOI: 10.3988/jcn.2023.0242] [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: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024] Open
Abstract
Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.
Collapse
Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA.
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France
| |
Collapse
|
5
|
Zhao X, Teng Y, Ni J, Li T, Shi J, Wei M. Systematic review: clinical characteristics of anti-N-methyl-D-aspartate receptor encephalitis. Front Hum Neurosci 2023; 17:1261638. [PMID: 38053649 PMCID: PMC10694196 DOI: 10.3389/fnhum.2023.1261638] [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: 07/19/2023] [Accepted: 10/16/2023] [Indexed: 12/07/2023] Open
Abstract
Background The number of reported cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis has gradually increased since its discovery in 2007, while there are no uniform treatment guidelines. Objective To summarize the clinical characteristics of patients with anti-NMDAR encephalitis and to analyze the factors affecting the disease prognosis. Methods A systematic analysis of medical records was conducted, and PubMed, Embase, and Cochrane Library were searched from January 1, 2011, to December 31, 2021. Data were extracted, analyzed, and recorded in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results This study included 472 case reports. Most patients had prodromal symptoms of about 2 weeks, including psychiatric symptoms (53.2%), flu-like symptoms (51.5%), and seizures (23.9%), among others. Poor prognoses were associated with patients who had autonomic instability (p = 0.010), central hypoventilation (p = 0.014), and ICU support (p = 0.002). Patients with a higher age of onset were more likely to develop central hypoventilation (OR 1.024, CI 1.006-1.042, p = 0.009), cognitive impairment (OR 1.023, CI 1.009-1.037, p = 0.001), and memory impairment (OR 1.034, CI 1.017-1.050, p < 0.001), whereas patients with a lower age were more likely to have seizures (OR 0.979, CI 0.965-0.993, p = 0.003). In this study, 97.0% of patients received immunotherapy, with the most commonly used treatment regimen being intravenous methylprednisolone (IVGC) and intravenous immunoglobulin (IVIG). When compared with other treatment regimens, the IVGC+IVIG regimen (p < 0.001) resulted in better prognoses. Conclusion When encountering patients with fever, headache, and initial psychiatric symptoms of unknown etiology, clinicians should test their CSF for antibodies to distinguish autoimmune encephalitis. Patients with autonomic instability, central hypoventilation, and ICU support had poorer prognoses. Clinicians should be aware that older patients are more likely to develop central hypoventilation, cognitive impairment, and memory impairment, while younger patients are more likely to develop seizures. The IVGC+IVIG treatment regimen has better prognoses than others. This study includes case reports, which have obvious selection bias, and there are no unified standards to measure the severity of the disease. Therefore, in the future, larger samples and randomized controlled trials are needed to evaluate the efficacy of different treatment regimens.
Collapse
Affiliation(s)
- Xi Zhao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuou Teng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingnian Ni
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ting Li
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Shi
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mingqing Wei
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
6
|
Siriratnam P, McArthur L, Chen Z, Kempster P, Monif M. Movement disorders in cell surface antibody mediated autoimmune encephalitis: a meta-analysis. Front Neurol 2023; 14:1225523. [PMID: 37545714 PMCID: PMC10401600 DOI: 10.3389/fneur.2023.1225523] [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: 05/23/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Background Autoimmune encephalitis (AE) is an increasingly recognized neuroinflammatory disease entity in which early detection and treatment leads to the best clinical outcomes. Movement disorders occur in AE but their characteristics are not well defined. Objectives To identify the frequency, classification, and prognostic significance of movement disorders in AE. Methods We conducted a systematic review and random-effects meta-analysis of movement disorders in cell surface antibody mediated AE. The frequency of any movement disorder as well as the classification of movement disorders in AE serotypes was determined. We looked at adults 18 years and older and included publications that described at least 10 cases. We used the following four electronic databases: Medline (Ovid), EMBASE (Ovid), APA Psychinfo, and Cochrane library. Results A total of 1,192 titles and abstracts were reviewed. Thirty-seven studies were included in the final meta-analysis. At least one kind of movement disorder was present in 40% of the entire AE cohort, 53% with anti-NMDA receptor antibodies, 33% with anti-CASPR2 antibodies, 30% with anti-LGI1 antibodies and 13% with anti-GABA receptor antibodies. Dyskinesia was the commonest movement disorder in anti-NMDA antibody mediated AE and faciobrachial dystonic seizures were most frequent in anti-LGI1 antibody mediated AE. Patients with a movement disorder tended to have a higher mortality. The risk of bias in the included studies was mostly moderate or high. Conclusion Movement disorders are common in AE and their identification, in conjunction with other clinical and paraclinical features, may facilitate earlier diagnosis. The prognostic implications of movement disorders in AE warrant further dedicated study. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42023386920.
Collapse
Affiliation(s)
- Pakeeran Siriratnam
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology, Alfred Health, Melbourne, VIC, Australia
| | | | - Zhibin Chen
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter Kempster
- Neurosciences Department, Monash Medical Centre, Clayton, VIC, Australia
- School of Clinical Sciences of Medicine, Monash University, Clayton, VIC, Australia
| | - Mastura Monif
- Neurosciences, The Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| |
Collapse
|
7
|
Wu Q, Xie Q, Liu L, Meng C, Wang J. Factors influencing prognosis and relapse in patients with anti-N-methyl-D-aspartate receptor encephalitis. Mult Scler Relat Disord 2023; 74:104697. [PMID: 37031550 DOI: 10.1016/j.msard.2023.104697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is the most common type of autoimmune encephalitis. Here, we investigated the factors associated with poor prognosis and relapse in patients with anti-NMDAR encephalitis. METHODS In this single-center observational cohort study, we retrospectively analyzed 51 patients with anti-NMDAR encephalitis treated in our hospital from January 2014 to October 2022. The demographic data, clinical characteristics, scale scores, results of auxiliary examination, and treatment details were statistically analyzed. Based on modified Rankin Scale (mRS) scores measured before final discharge, patients were divided into groups with good (mRS score 0-2) and poor (mRS score 3-6) prognoses for functional evaluation. The chi-squared test or Fisher's exact test was used to compare categorical data, and the t-test and Mann-Whitney U test were used to compare normally and non-normally distributed continuous data, respectively. Binary logistic regression was used to identify the risk factors for prognosis and relapse. RESULTS At admission, the main clinical manifestations observed were psychobehavioral disorders (50 cases, 98.0%), consciousness disorders (28 cases, 54.9%), epilepsy (33 cases, 64.7%), motor disorders (28 cases, 54.9%), speech disorders (24 cases, 47.1%), and dysfunction of the autonomic nervous system (15 cases, 29.4%). All 51 patients (100%) had mRS scores of 3-5 at admission, and 50 were treated with intravenous methylprednisolone and human immunoglobulin. A total of 22 patients (43.1%) had an mRS score of 3-6 at discharge, which was significantly lower than those at admission. One patient died (mRS score 6) after developing septic shock (fatality rate 1.9%). Binary logistic regression analysis showed that movement disorders/involuntary movement (odds ratios [OR] 3.778, p = 0.029), abnormal brain magnetic resonance imaging (OR 4.817, p = 0.013), electroencephalogram slow wave activity of >50% (OR 8.400, p = 0.001), a white blood cell count of >10 × 106/L in the cerebrospinal fluid (OR 3,210, p = 0.048), and male sex (OR 3.282, p = 0.050) were risk factors for poor prognosis. A duration of disease of >12 months (OR 8.800, p = 0.001) and first-line-immunotherapy for less than 3 months after first onset (OR 3.719, p = 0.048) were identified as risk factors for relapse. CONCLUSION Motor disorders or involuntary movement, abnormal brain magnetic resonance imaging, electroencephalogram slow wave activity >50%, and elevated white blood cell counts in cerebrospinal fluid were associated with poor prognosis in patients with NMDAR encephalitis. First-line immunotherapy less than 3 months after first onset may be a risk factor for relapse.
Collapse
|
8
|
Piao S, Bao Y, Yang L, Zhang Y, Hu B, Li H, Geng D, Li Y. Brain MRI features of anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis secondary to central nervous system infection in adult patients. Acta Radiol 2023; 64:760-768. [PMID: 35532900 DOI: 10.1177/02841851221091443] [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: 11/15/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis secondary to central nervous system (CNS) infection is a unique subtype of the autoimmune-mediated disease, of which the imaging features are unclear. PURPOSE To compare the brain magnetic resonance imaging (MRI) features between the anti-NMDAR encephalitis secondary to CNS infection and that without initial infection. MATERIAL AND METHODS A total of 70 adult patients with anti-NMDAR encephalitis were retrospectively enrolled (24 in the post-infection group, 46 in the non-infection-related group). Their clinical and imaging features (lesion distribution, lesion shape, enhancement pattern, brain atrophy) were reviewed and summarized. Lesion distributions were compared between the two groups on lesion probability maps. RESULTS The patients with normal brain MRI scans in the post-infection group were less than those in the non-infection related group (29% vs. 63%; P = 0.0113). Among the 24 patients in the post-infection group, visible lesions were shown at the anti-NMDAR encephalitis onset in 17 patients; lesion distribution was more diffuse than the non-infection-related group, showing higher lesion peak probabilities in the bilateral hippocampus, frontal lobe, temporal lobe, insula, and cingulate. The lesions with contrast enhancement were also more common in the post-infection group than the non-infection-related group (7/13 vs. 2/10). Brain atrophy was observed in eight patients in the post-infection group and three in the non-infection-related group. CONCLUSION Anti-NMDAR encephalitis secondary to CNS infection has its imaging features-extensive lesion distribution, leptomeningeal enhancement, early atrophy, and necrosis-that could deepen the understanding of the pathophysiology and manifestation of the autoimmune encephalitis besides the classic type.
Collapse
Affiliation(s)
- Sirong Piao
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| | - Yifang Bao
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Liqin Yang
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Yi Zhang
- Department of Infectious Disease, Huashan Hospital, 159397Fudan University, Shanghai, PR China
| | - Bin Hu
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Haiqing Li
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, PR China
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| | - Yuxin Li
- Department of Radiology, Huashan Hospital, 535039Fudan University, Shanghai, PR China
| |
Collapse
|
9
|
Wang ZH, Qiao S, Wang L, Wang K, Zhang R, Jin Y, Wu HK, Liu X. Plasma lipid profiles and homocysteine levels in anti-N-methyl-D-aspartate receptor encephalitis. Front Neurol 2023; 14:1148450. [PMID: 37122291 PMCID: PMC10133572 DOI: 10.3389/fneur.2023.1148450] [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: 01/20/2023] [Accepted: 03/15/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction We aimed to investigate whether lipid profiles and homocysteine levels in patients with anti-N-methyl-D-aspartate receptor encephalitis are related to clinical presentation and prognosis, which may contribute to further research on the pathogenesis and treatment of this disease. Methods This study included a total of 43 patients with anti-N-methyl-D-aspartate receptor encephalitis and 43 sex-age-matched healthy controls. Baseline demography, clinical data, patient outcomes, and ancillary examination results were recorded. Patients were followed up every 2-3 months during the first year. The modified Rankin Scale score was used to evaluate the therapeutic effect and clinical outcome. Results Among the 43 patients included in this study, 55.81% were male, the mean age of onset was 27 years old, and the median modified Rankin Scale score on admission was 3.0. Apolipoprotein A-1 was significantly lower in patients with anti-N-methyl-D-aspartate receptor encephalitis compared with healthy controls (p = 0.004). Compared with healthy controls, homocysteine (p = 0.002), apolipoprotein B (p = 0.004), Lpa (p = 0.045), and apolipoprotein B/apolipoprotein A-1 (p = 0.001) were significantly increased in patients with anti-N-methyl-D-aspartate receptor encephalitis. According to the modified Rankin Scale scores, 6 months after discharge, 72.09% of patients had a good prognosis and 27.91% had a poor prognosis. In the good prognosis group, age (p = 0.031), lipoprotein a (p = 0.023), apolipoprotein A-1 (p = 0.027) at baseline, and the modified Rankin Scale score on admission (p = 0.019) were significantly higher than those in the poor prognosis group. Conclusion This study suggests the possibility that serum lipid profile and homocysteine play an important role in the pathogenesis of anti-N-methyl-D-aspartate receptor encephalitis, providing support for lipid-lowering treatment of anti-N-methyl-D-aspartate receptor encephalitis patients.
Collapse
Affiliation(s)
- Zhi-hao Wang
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Shan Qiao
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Lei Wang
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Kemo Wang
- Department of Neurology of Stroke Center, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ranran Zhang
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Yang Jin
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Huai-kuan Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xuewu Liu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
- Institute of Epilepsy, Shandong University, Jinan, China
- *Correspondence: Xuewu Liu
| |
Collapse
|
10
|
Liu Y, Ma X, Ma L, Su Z, Li D, Chen X. Elevated ApoB/ApoA-I ratio is associated with acute anti-N-Methyl-D-aspartate receptor encephalitis, but not disease outcomes. Front Neurol 2022; 13:896656. [PMID: 36119695 PMCID: PMC9475113 DOI: 10.3389/fneur.2022.896656] [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] [Received: 03/15/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
Objective The purpose of the present study is to clarify the relationship between the apolipoprotein B100/apolipoprotein A-I (ApoB/ApoA-I) ratio and anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. Methods A total of 71 patients with anti-NMDAR encephalitis were included in this study, and their ApoB/ApoA-I ratios in baseline and follow-up were retrospectively analyzed. Results The ApoB/ApoA-I ratio was closely correlated with the baseline-modified Rankin scale (mRS) score of >3 in patients with anti-NMDAR encephalitis. A subgroup analysis showed obvious differences between the high and low ApoB/ApoA-I ratio groups. The ApoB/ApoA-I ratio was positively correlated with intensive care unit (ICU) treatment, length of hospital stay, baseline mRS score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The ratios of the high and low ApoB/ApoA-I groups both improved in the follow-up. Conclusion The increased ApoB/ApoA-I ratio is associated with acute anti-NMDAR encephalitis, but not disease outcomes. Serum ApoB/ApoA-I ratio was related to inflammation and immunity in peripheral blood. The findings might provide a new idea for further exploration of the pathogenesis and treatment of anti-NMDAR encephalitis.
Collapse
|
11
|
Anurat K, Watcharakuldilok P, Sakpichaisakul K, Khongkhatithum C, Mahasirimongkol S, Kunhapan P, Inunchot W, Wattanapokayakit S, Munggaranonchai O, Thampratankul L. HLA-DRB1∗1502 Is Associated With Anti-N-Methyl-D-aspartate Receptor Encephalitis in Thai Children. Pediatr Neurol 2022; 134:93-99. [PMID: 35863207 DOI: 10.1016/j.pediatrneurol.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is one of the most common types of autoimmune encephalitis. Most patients have no apparent immunologic triggers, which suggests a genetic predisposition. This study was conducted to identify human leukocyte antigen (HLA) class II alleles associated with anti-NMDARE in Thai children. METHODS This case-control study enrolled patients younger than 18 years who were diagnosed with anti-NMDARE between January 2010 and December 2020. A "good outcome" was determined as a patient with a modified Rankin scale score of less than 2 at any follow-up visit. HLA genotypes were determined at four-digit alleles using reverse sequence-specific oligonucleotide probe hybridization. The HLA class II allele frequency in patients was compared with that in a database of 101 healthy control Thai children. RESULTS Thirty-four patients were enrolled with a mean age of 12.8 ± 5.6 years (females 85.3%). The HLA-DRB1∗1502 allele frequency was significantly higher in patients than in controls (odds ratio, 2.32; 95% confidence interval, 1.11-4.8, P = 0.023). A good outcome was noted in 14 of 14 (100%) HLA-DRB1∗1502-positive patients (median time to a good outcome, 6 months) and 14 of 17 (82.3%) HLA-DRB1∗1502-negative patients (median time to a good outcome, 3 months). Two (11.8%) HLA-DRB1∗1502-positive patients had one relapse each, and six (35.3%) HLA-DRB1∗1502-negative patients had one to three relapses. CONCLUSIONS HLA-DRB1∗1502 was significantly associated with anti-NMDARE in our patients. Most patients had good outcomes. HLA-DRB1∗1502-positive patients tended to require a longer time to achieve a good outcome but had less frequent relapses than HLA-DRB1∗1502-negative patients.
Collapse
Affiliation(s)
- Kingthong Anurat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | | | - Kullasate Sakpichaisakul
- Department of Pediatrics, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Chaiyos Khongkhatithum
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surakameth Mahasirimongkol
- Department of Medical Sciences, Medical Genetics Section, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Punna Kunhapan
- Department of Medical Sciences, Medical Genetics Section, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Wimala Inunchot
- Department of Medical Sciences, Medical Genetics Section, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Sukanya Wattanapokayakit
- Department of Medical Sciences, Medical Genetics Section, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Orathai Munggaranonchai
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lunliya Thampratankul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
12
|
Yao Y, Zhang O, Gu L, Zhang X. Analysis of risk factors for a poor functional prognosis and relapse in patients with autoimmune encephalitis. J Neuroimmunol 2022; 369:577899. [DOI: 10.1016/j.jneuroim.2022.577899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/23/2022] [Accepted: 05/22/2022] [Indexed: 12/18/2022]
|
13
|
Zhong R, Chen Q, Zhang X, Zhang H, Lin W. Relapses of Anti-NMDAR, Anti-GABABR and Anti-LGI1 Encephalitis: A Retrospective Cohort Study. Front Immunol 2022; 13:918396. [PMID: 35757705 PMCID: PMC9218051 DOI: 10.3389/fimmu.2022.918396] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/17/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate the relapse rate and study the factors that may predict the subsequent relapse in anti-NMDAR, anti-GABABR and anti-LGI1 encephalitis in Northeast China. Methods In the retrospective cohort study, we consecutively enrolled patients with anti-N1MDAR, anti-GABABR and anti-LGI1 encephalitis between March 2015 and November 2021. The patients were followed up for at least 6 months. The outcome variable was a binary variable of relapse or not. Predictors of relapse were identified. Results A total of 100 patients were enrolled. Relapse occurred in 26 (26%) patients after a median follow-up of 18 months since the first event. The relapse rates of anti - NMDAR, anti - GABABR and anti - LGI1 encephalitis were 25%, 33.3%, and 28.6%, respectively. The multivariable analysis results suggested that immunotherapy delay at the acute phase was independently associated with an increased risk of relapse in total patients (HR = 2.447, 95% CI = 1.027 - 5.832; P = 0.043). Subgroup analysis results showed that antibody titer was associated with the likelihood of relapse in anti-LGI1 encephalitis. The higher the concentration, the more likely it was for patients to have relapse (p=0.019). Conclusion The general relapse rate of anti-NMDAR, anti-GABABR and anti-LGI1 encephalitis was 26%. The risk of subsequent relapse was elevated in those with delayed immunotherapy in the first episode. In subgroup of anti-LGI1 encephalitis, higher antibody titer was the risk factors of relapse. Thus, timely and aggressive immunotherapy may be beneficial for patients to prevent subsequent relapse.
Collapse
Affiliation(s)
- Rui Zhong
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qingling Chen
- Department of Hepatology, Second People's Clinical College of Tianjin Medical University, Tianjin, China
| | - Xinyue Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hanyu Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
14
|
Shahrestani S, Brown NJ, Singh R, Kurtz JS, Patel NA, Himstead AS, Nasrollahi T, Borrelli M, Pierzchajlo N, Ransom SC, Gendreau J. Evaluating the incidence and predictors of anti-NMDAR encephalitis in a contemporary cohort of patients diagnosed with dermoid tumors: A national inpatient sample analysis. J Clin Neurosci 2022; 102:109-113. [PMID: 35777113 DOI: 10.1016/j.jocn.2022.06.018] [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: 03/25/2022] [Revised: 06/02/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a form of encephalitis previously associated with dermoid tumors. However, most studies in the literature evaluating the disease are case reports and small patient cohorts, limiting robust statistical analysis. Here, we demonstrate predictors of anti-NMDAR encephalitis in a large cohort of US patients. METHODS We used the 2016 National Inpatient Sample (NIS) to identify a cohort of 24,270 admitted for an ovarian dermoid tumor. Of these patients, 50 (0.21%) were diagnosed with anti-NMDAR encephalitis. Patient demographics, hospital characteristics, length of stay (LOS), and complications were collected. Statistical analysis consisted of odds ratios with chi-square testing to compare categorical variables. RESULTS The mean age of all patients with dermoid tumors was 45.5 ± 18.0 years, and the mean age of patients with diagnosed anti-NMDAR encephalitis was 27.4 ± 4.9 years. The mean LOS in the dermoid tumor cohort was 3.5 ± 4.9 days, while the mean LOS in the anti-NMDAR encephalitis cohort was 31.9 ± 25.9 days (p < 0.001). The mean cost in the dermoid tumor cohort was $44,813.18±$54,305.90, while the mean cost in the anti-NMDAR encephalitis cohort was $445,628.60±$665,423.40 (p < 0.001). Patients with age above 30 years with dermoid tumors had significantly lower odds of developing anti-NMDAR encephalitis compared to patients younger than 30 years (OR: 0.19; 95%CI: 0.045-0.67; p-value: 0.003). White patients had significantly lower odds of developing anti-NMDAR encephalitis (OR: 0.19; 95%CI: 0.026-0.77; p-value: 0.013), and Black patients had significantly higher odds of developing anti-NMDAR encephalitis (OR: 3.45; 95%CI: 1.00-12.46; p-value: 0.044). CONCLUSION Patient predictors of developing anti-NMDAR encephalitis include age, race, ethnicity and patients who go on to develop anti-NMDAR encephalitis have a significantly increased hospital LOS and cost compared to those who do not. Future research, including multi-center clinical trials and longitudinal data, is necessary to fully cement the findings of this manuscript.
Collapse
Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, CA, USA
| | - Rohin Singh
- School of Medicine, University of California, Irvine, CA, USA
| | - Joshua S Kurtz
- School of Medicine, University of California, Irvine, CA, USA
| | - Neal A Patel
- Mercer University School of Medicine, Macon, GA, USA
| | | | - Tasha Nasrollahi
- Department of Otolaryngology, Head and Neck Surgery, Cedars Sinai School of Medicine, Los Angeles, CA, USA
| | - Michela Borrelli
- Department of Otolaryngology, Head and Neck Surgery, Cedars Sinai School of Medicine, Los Angeles, CA, USA
| | | | - Seth C Ransom
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| |
Collapse
|
15
|
Xiang Y, Dong X, Zeng C, Liu J, Liu H, Hu X, Feng J, Du S, Wang J, Han Y, Luo Q, Chen S, Li Y. Clinical Variables, Deep Learning and Radiomics Features Help Predict the Prognosis of Adult Anti-N-methyl-D-aspartate Receptor Encephalitis Early: A Two-Center Study in Southwest China. Front Immunol 2022; 13:913703. [PMID: 35720336 PMCID: PMC9199424 DOI: 10.3389/fimmu.2022.913703] [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: 04/06/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To develop a fusion model combining clinical variables, deep learning (DL), and radiomics features to predict the functional outcomes early in patients with adult anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in Southwest China. Methods From January 2012, a two-center study of anti-NMDAR encephalitis was initiated to collect clinical and MRI data from acute patients in Southwest China. Two experienced neurologists independently assessed the patients’ prognosis at 24 moths based on the modified Rankin Scale (mRS) (good outcome defined as mRS 0–2; bad outcome defined as mRS 3-6). Risk factors influencing the prognosis of patients with acute anti-NMDAR encephalitis were investigated using clinical data. Five DL and radiomics models trained with four single or combined four MRI sequences (T1-weighted imaging, T2-weighted imaging, fluid-attenuated inversion recovery imaging and diffusion weighted imaging) and a clinical model were developed to predict the prognosis of anti-NMDAR encephalitis. A fusion model combing a clinical model and two machine learning-based models was built. The performances of the fusion model, clinical model, DL-based models and radiomics-based models were compared using the area under the receiver operating characteristic curve (AUC) and accuracy and then assessed by paired t-tests (P < 0.05 was considered significant). Results The fusion model achieved the significantly greatest predictive performance in the internal test dataset with an AUC of 0.963 [95% CI: (0.874-0.999)], and also significantly exhibited an equally good performance in the external validation dataset, with an AUC of 0.927 [95% CI: (0.688-0.975)]. The radiomics_combined model (AUC: 0.889; accuracy: 0.857) provided significantly superior predictive performance than the DL_combined (AUC: 0.845; accuracy: 0.857) and clinical models (AUC: 0.840; accuracy: 0.905), whereas the clinical model showed significantly higher accuracy. Compared with all single-sequence models, the DL_combined model and the radiomics_combined model had significantly greater AUCs and accuracies. Conclusions The fusion model combining clinical variables and machine learning-based models may have early predictive value for poor outcomes associated with anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Yayun Xiang
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaoxuan Dong
- College of Computer and Information Science, Chongqing, China
| | - Chun Zeng
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Junhang Liu
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hanjing Liu
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaofei Hu
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jinzhou Feng
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Silin Du
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yongliang Han
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qi Luo
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Shanxiong Chen
- College of Computer and Information Science, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| |
Collapse
|
16
|
Zhao Y, Ren B, Yu W, Zhang H, Zhao D, Lv J, Xie Z, Jiang K, Shang L, Yao H, Xu Y, Zhao G. Construction of an Assisted Model Based on Natural Language Processing for Automatic Early Diagnosis of Autoimmune Encephalitis. Neurol Ther 2022; 11:1117-1134. [PMID: 35543808 PMCID: PMC9338198 DOI: 10.1007/s40120-022-00355-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Early diagnosis and etiological treatment can effectively improve the prognosis of patients with autoimmune encephalitis (AE). However, anti-neuronal antibody tests which provide the definitive diagnosis require time and are not always abnormal. By using natural language processing (NLP) technology, our study proposes an assisted diagnostic method for early clinical diagnosis of AE and compares its sensitivity with that of previously established criteria. Methods Our model is based on the text classification model trained by the history of present illness (HPI) in electronic medical records (EMRs) that present a definite pathological diagnosis of AE or infectious encephalitis (IE). The definitive diagnosis of IE was based on the results of traditional etiological examinations. The definitive diagnosis of AE was based on the results of neuronal antibodies, and the diagnostic criteria of definite autoimmune limbic encephalitis proposed by Graus et al. used as the reference standard for antibody-negative AE. First, we automatically recognized and extracted symptoms for all HPI texts in EMRs by training a dataset of 552 cases. Second, four text classification models trained by a dataset of 199 cases were established for differential diagnosis of AE and IE based on a post-structuring text dataset of every HPI, which was completed using symptoms in English language after the process of normalization of synonyms. The optimal model was identified by evaluating and comparing the performance of the four models. Finally, combined with three typical symptoms and the results of standard paraclinical tests such as cerebrospinal fluid (CSF), magnetic resonance imaging (MRI), or electroencephalogram (EEG) proposed from Graus criteria, an assisted early diagnostic model for AE was established on the basis of the text classification model with the best performance. Results The comparison results for the four models applied to the independent testing dataset showed the naïve Bayesian classifier with bag of words achieved the best performance, with an area under the receiver operating characteristic curve of 0.85, accuracy of 84.5% (95% confidence interval [CI] 74.0–92.0%), sensitivity of 86.7% (95% CI 69.3–96.2%), and specificity of 82.9% (95% CI 67.9–92.8%), respectively. Compared with the diagnostic criteria proposed previously, the early diagnostic sensitivity for possible AE using the assisted diagnostic model based on the independent testing dataset was improved from 73.3% (95% CI 54.1–87.7%) to 86.7% (95% CI 69.3–96.2%). Conclusions The assisted diagnostic model could effectively increase the early diagnostic sensitivity for AE compared to previous diagnostic criteria, assist physicians in establishing the diagnosis of AE automatically after inputting the HPI and the results of standard paraclinical tests according to their narrative habits for describing symptoms, avoiding misdiagnosis and allowing for prompt initiation of specific treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00355-7.
Collapse
Affiliation(s)
- Yunsong Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Bin Ren
- Department of Information, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wenjin Yu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Haijun Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Di Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Junchao Lv
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhen Xie
- College of Life Sciences and Medicine, Northwest University, Xi'an, China
| | - Kun Jiang
- Department of Information, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Han Yao
- Department of Neurobiology, School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Yongyong Xu
- College of Life Sciences and Medicine, Northwest University, Xi'an, China.
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
- College of Life Sciences and Medicine, Northwest University, Xi'an, China.
| |
Collapse
|
17
|
Chen Z, Zhang Y, Wu X, Huang H, Chen W, Su Y. Characteristics and Outcomes of Paroxysmal Sympathetic Hyperactivity in Anti-NMDAR Encephalitis. Front Immunol 2022; 13:858450. [PMID: 35464412 PMCID: PMC9020260 DOI: 10.3389/fimmu.2022.858450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background To explore the clinical characteristics and prognosis of autonomic dysfunction and paroxysmal sympathetic hyperactivity (PSH), and evaluate the efficacy of drugs used to suppress PSH episode in anti-NMDAR encephalitis patients. Methods Patients who met the diagnostic criteria of anti-NMDAR encephalitis were enrolled from January 2012 to August 2018 and followed up for 2 years. PSH was diagnosed according to the PSH-Assessment Measure. The demographics data, clinical features, auxiliary tests results, treatments, and outcomes were prospective collected and analyzed. Results A total of 132 anti-NMDAR encephalitis patients were enrolled, of which 27.3% and 9.1% experienced autonomic dysfunction and probable PSH respectively. Cardiac autonomic dysfunction was the most common subtype (77.8%). Patients with a higher incidence of ovarian teratoma, mechanical ventilation, neurological intensive care unit admission, and elevated glucose and NMDAR antibody titer in the CSF were more likely to exhibit autonomic dysfunction or PSH. Episodes of PSH can be suppressed by monotherapy in patients without prior sedative drug use with an efficacy of 90%. No significant difference was observed between the prognosis of patients with or without autonomic dysfunction, or between the PSH versus non-PSH groups after 6 months and even during long-term follow-up. However, patients with cardiac autonomic dysfunction had poor prognosis at 6 months. Conclusion PSH is a common clinical condition in patients with anti-NMDAR encephalitis, especially in severe cases, and can be effectively managed by several drug monotherapies. Despite necessitating longer hospital stay, autonomic dysfunction or PSH do not seem to compromise the neurological recovery of patients.
Collapse
Affiliation(s)
- Zhongyun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaowen Wu
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
18
|
Zhao Y, Wang H, Wang M, Yuan B, Sun T, Xu Y. Relapse factors of patients of anti-N-methyl-D-aspartate receptor encephalitis. Acta Neurol Scand 2022; 145:434-441. [PMID: 34927233 DOI: 10.1111/ane.13568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The factors associated with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis relapse are yet to be elucidated. AIMS OF THE STUDY To investigate the factors associated with relapse and prognosis of anti-NMDA receptor encephalitis. METHODS This retrospective study included patients diagnosed with anti-NMDA receptor encephalitis admitted to the First Affiliated Hospital of Zhengzhou University from January 2013 to October 2019. The clinical features, auxiliary examinations, treatment regimens, and follow-up were recorded. The outcomes were relapse and 2-year disease prognosis. RESULTS A total of 160 patients were included. Consequently, 6 (5%) deaths, 34 (25.4%) relapses, and 19 (15.2%) patients had a poor prognosis (modified Rankin score (mRS) ≥3) were recorded. The multivariable analyses showed that age (p = .011), abnormal magnetic resonance imaging (MRI) (p = .019), glucocorticoid pulse (p = .009), and intracranial pressure (p = .023) were independently associated with the relapse, while age (p = .030) and central hypoventilation (p = .020) were independently associated with a poor prognosis at 2 years. CONCLUSION Glucocorticoid pulse therapy reduces the relapse of anti-NMDA receptor encephalitis. Age, abnormal MRI, and intracranial pressure are risk factors for relapse, while age and central hypoventilation are independently associated with poor prognosis.
Collapse
Affiliation(s)
- Ying‐Ying Zhao
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Hai‐Xu Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Meng Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Bo Yuan
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Tong‐Wen Sun
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Yu‐Ming Xu
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| |
Collapse
|
19
|
Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. The prognosis of late-onset anti-N-methyl-D-aspartate receptor encephalitis in China. Acta Neurol Scand 2022; 145:449-455. [PMID: 34918336 DOI: 10.1111/ane.13571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/27/2021] [Accepted: 12/05/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Early-onset anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) differs from late-onset anti-NMDARE regarding clinical characteristics. Until recently, research focusing on prognosis of elder adults has been scarce and showed inconsistent results. This study aims to evaluate the prognosis of late-onset anti-NMDARE in China. MATERIALS & METHODS One hundred and twelve adults diagnosed as anti-NMDARE in four hospitals in China were reviewed retrospectively. Outcome data were assessed using modified Rankin Scale (mRS) score in short term (3 months after discharge) and long term (≥12 months after discharge). The relapse rate was also computed. Multivariable logistic regression was used to evaluate whether there are substantial differences in functional outcomes and recurrence rate across two groups. RESULTS Of the 112 patients with anti-NMDARE, 81 (72.3%) were early-onset disease and 31 (27.7%) were late-onset disease. Of these, all had short-term follow-up and 70 completed long-term follow-up. Late-onset anti-NMDARE group showed better short-term (OR 2.70, 95% CI 1.09-6.71) and long-term prognoses (OR 10.25, 95% CI 1.90-55.15). Recurrence rates were statistically different between the groups (OR 4.25, 95% CI 1.22-14.75). CONCLUSION The prognosis for anti-NMDARE in China was poorer for older adults relative to younger adults. The relapse rates were higher in late-onset group compared to early-onset group.
Collapse
Affiliation(s)
- Yueqian Sun
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Guoping Ren
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
| | - Jiechuan Ren
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
| | - Wei Shan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
- Collaborative Innovation Center for Brain Disorders Beijing Institute of Brain Disorders Capital Medical University Beijing China
| | - Xiong Han
- Department of Neurology Henan Provincial People's Hospital Henan China
| | - Yajun Lian
- Department of Neurology The First Affiliated Hospital of Zhengzhou University Henan China
| | - Tiancheng Wang
- Department of Neurology The Second Hospital of Lanzhou University Gansu China
| | - Qun Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
- Collaborative Innovation Center for Brain Disorders Beijing Institute of Brain Disorders Capital Medical University Beijing China
| |
Collapse
|
20
|
Lei C, Chang X, Li H, Zhong L. Abnormal Brain MRI Findings in Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Correlation With Outcomes. Front Neurol 2022; 13:834929. [PMID: 35359628 PMCID: PMC8963947 DOI: 10.3389/fneur.2022.834929] [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] [Received: 12/14/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The reported prevalence of abnormal findings by brain MRI varies from 11 to 83% among patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Here, we investigated the prevalence of abnormal MRI findings in Chinese patients and explored whether such findings are correlated with clinical outcomes. Methods This retrospective study analyzed a consecutive series of 52 patients with anti-NMDAR encephalitis admitted to our hospital. The patients were assigned to the “MRI-normal” or the “MRI-abnormal” group based on brain MRI after admission. The groups were compared in terms of clinicodemographic characteristics and scores on the Mini-Mental State Examination (MMSE) and modified Rankin Scale (mRS) 3 and 12 months after admission. Results Thirty-seven (71.15%) of the patients showed abnormalities on brain MRI; these patients were more likely to be men and showed abnormalities on electroencephalography. Patients who showed normal or abnormal MRI findings did not differ significantly in terms of clinical symptoms, rates of mortality or relapse, or mRS scores after 3 and 12 months. However, patients with abnormal MRI showed significantly lower MMSE scores than those with normal MRI after 3 and 12 months. Conclusions We found high prevalence of abnormal MRI findings in our sample of Chinese patients with anti-NMDAR encephalitis. We also found that the abnormal findings were associated with cognitive decline but not necessarily with mortality or functional outcomes in the short or long term.
Collapse
|
21
|
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.
Collapse
Affiliation(s)
| | | | | | | | | | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
22
|
Zhong R, Chen Q, Zhang X, Zhang H, Lin W. Risk Factors for Mortality in Anti-NMDAR, Anti-LGI1, and Anti-GABABR Encephalitis. Front Immunol 2022; 13:845365. [PMID: 35320933 PMCID: PMC8934853 DOI: 10.3389/fimmu.2022.845365] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/11/2022] [Indexed: 12/23/2022] Open
Abstract
ObjectiveWe aimed to investigate the mortality rate and identify the predictors of death in patients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis.MethodsPatients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis were recruited from the Neurology Department of the First Hospital of Jilin University from March 2015 to November 2021. The primary outcome variable was a binary variable of death vs. survival. The potential risk factors for mortality were evaluated. The mortality rates were determined, and the independent predictors of death were identified using multivariable logistic regression analysis.ResultsA total of 100 hospitalized patients with anti-NMDAR, anti-LGI1, or anti-GABABR encephalitis were included in the final analysis. Fifteen patients (15%) died during a median follow-up period of 18 months. The mortality rates were 10% for anti-NMDAR encephalitis, 2.8% for anti-LGI1 encephalitis, and 41.7% for anti-GABABR encephalitis. The multivariable analysis results showed that older age at onset [adjusted odds ratio (OR) = 1.017, 95% confidence interval (CI) = 1.009–1.136; p = 0.023] was independently associated with an increased risk of death. Antibody type was also associated with mortality. Patients with anti-GABABR encephalitis had 13.458-fold greater odds of dying than patients with anti-LGI1 encephalitis (adjusted OR = 13.458, 95% CI = 1.270–142.631; p = 0.031).ConclusionThe general mortality rate of anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis was 15%. Age at onset and type of autoimmune encephalitis antibody were independent predictors of death in these patients.
Collapse
Affiliation(s)
- Rui Zhong
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qingling Chen
- Department of Hepatology, Second People’s Clinical College of Tianjin Medical University, Tianjin, China
| | - Xinyue Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hanyu Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Weihong Lin,
| |
Collapse
|
23
|
Zhang Y, Tu E, Yao C, Liu J, Lei Q, Lu W. Validation of the Clinical Assessment Scale in Autoimmune Encephalitis in Chinese Patients. Front Immunol 2022; 12:796965. [PMID: 34975905 PMCID: PMC8718556 DOI: 10.3389/fimmu.2021.796965] [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: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background and Objectives The Clinical Assessment Scale in Autoimmune Encephalitis (CASE) is a scale for assessing severity in autoimmune encephalitis. We aimed to validate the CASE score in a Chinese population and evaluate its clinical significance. Methods Patients diagnosed with autoimmune encephalitis were recruited between June 2014 and May 2019 from two hospitals. CASE and modified Rankin Scale (mRS) scores were obtained. Data regarding clinical features, treatment, and available information were gathered from the hospital information system. Results Of the 176 patients with autoimmune encephalitis, 11 died and 14 had tumors. Ten patients received second-line treatment. The CASE scores of patients receiving second-line treatment were significantly higher (median CASE: 15) than in those receiving first-line treatment (median CASE: 8) (p<0.001). Twenty-two patients had poor functional status (mRS>2). Areas under the curve of CASE on whether functional status was poor at 1 year were 0.89 (p<0.001). Sixty patients were admitted to the intensive care unit (ICU), and the CASE scores were positively correlated with days in the ICU (r=0.58, p<0.001). There was no statistically significant association between the CASE scores and relapse (p=0.39>0.05). Additionally, the CASE scores were positively associated with the mRS scores (r=0.85 p<0.001). Conclusions The CASE score is suitable for the comprehensive assessment of Chinese patients with autoimmune encephalitis, which may help clinicians to select the appropriate intervention and estimate the disease severity and prognosis.
Collapse
Affiliation(s)
- Yingchi Zhang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ewen Tu
- Department of Neurology, The Second Hospital of Hunan Province, Hunan University of Chinese Medicine, Changsha, China
| | - Chenxiao Yao
- Department of Neurology, The Second Hospital of Hunan Province, Hunan University of Chinese Medicine, Changsha, China
| | - Jia Liu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiang Lei
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
24
|
Radosevic M, Planagumà J, Mannara F, Mellado A, Aguilar E, Sabater L, Landa J, García-Serra A, Maudes E, Gasull X, Lewis M, Dalmau J. Allosteric Modulation of NMDARs Reverses Patients' Autoantibody Effects in Mice. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/1/e1122. [PMID: 34903638 PMCID: PMC8669659 DOI: 10.1212/nxi.0000000000001122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
Abstract
Background and Objectives To demonstrate that an analog (SGE-301) of a brain-derived cholesterol metabolite, 24(S)-hydroxycholesterol, which is a selective positive allosteric modulator (PAM) of NMDA receptors (NMDARs), is able to reverse the memory and synaptic alterations caused by CSF from patients with anti-NMDAR encephalitis in an animal model of passive transfer of antibodies. Methods Four groups of mice received (days 1–14) patients' or controls' CSF via osmotic pumps connected to the cerebroventricular system and from day 11 were treated with daily subcutaneous injections of SGE-301 or vehicle (no drug). Visuospatial memory, locomotor activity (LA), synaptic NMDAR cluster density, hippocampal long-term potentiation (LTP), and paired-pulse facilitation (PPF) were assessed on days 10, 13, 18, and 26 using reported techniques. Results On day 10, mice infused with patients' CSF, but not controls' CSF, presented a significant visuospatial memory deficit, reduction of NMDAR clusters, and impairment of LTP, whereas LA and PPF were unaffected. These alterations persisted until day 18, the time of maximal deficits in this model. In contrast, mice that received patients' CSF but from day 11 were treated with SGE-301 showed memory recovery (day 13), and on day 18, all paradigms (memory, NMDAR clusters, and LTP) had reversed to values similar to those of controls. On day 26, no differences were observed among experimental groups. Discussion An oxysterol biology-based PAM of NMDARs is able to reverse the synaptic and memory deficits caused by CSF from patients with anti-NMDAR encephalitis. These findings suggest a novel adjuvant treatment approach that deserves future clinical evaluation.
Collapse
|
25
|
Dou X, Li D, Wu F, Wang Z, Niu M, Wu Y, Deng T, Wang D, Li X. The clinical features, treatment and outcomes of 33 children from Northwestern China with Anti-N-methyl-D-aspartate receptor encephalitis. Neurol Res 2021; 44:429-438. [PMID: 34806564 DOI: 10.1080/01616412.2021.2000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES We analyzed the clinical features and outcomes of children with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis in Northwestern China. METHODS We retrospectively recruited 33 pediatric patients with anti-NMDAR encephalitis in Northwestern China from December 2013 to April 2020. The demographics, clinical features, treatments, and outcomes were reviewed. RESULTS 33 patients with anti-NMDAR encephalitis were enrolled in this study (a median age of 6.8 years, 20 females and 13 males). The initial symptoms included seizures (42.4%), psychiatric symptoms (39.4%), speech dysfunction (12.1%), and paralysis (6.1%). During the course of the disease, 31 patients (93.9%) presented with psychiatric symptoms, 29 patients (87.9%) presented with speech dysfunction, 25 patients (75.8%) presented with movement disorders and 24 patients (72.7%) presented with sleep disorders followed by seizures, consciousness disturbance, autonomic nervous dysfunction, paralysis, and hypoventilation. 12 patients (36.4%) had abnormal cerebrospinal fluid (CSF) findings, 10 patients (30.3%) exhibited abnormal brain magnetic resonance imaging (MRI) results, and 29 patients (87.9%) showed abnormal Electroencephalography (EEG) findings. None of the patients had tumors. All patients received first-line immunotherapy and 8 patients both received first and second-line immunotherapy. 30 of the 33 patients achieved good outcomes (score on the modified Rankin Scale [mRS] of 0-2), whilst the other 3 patients had poor outcomes (mRS score of 3-6). CONCLUSIONS Patients with higher CSF anti-NMDAR body titer were more likely to develop sleep disorders, consciousness disturbances and more severe disease states.
Collapse
Affiliation(s)
- Xiangjun Dou
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Dongjing Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Fang Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Zhijing Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Mengmeng Niu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - You Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Ting Deng
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Dong Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| | - Xia Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, China
| |
Collapse
|
26
|
Xu Q, Wang Q, Han J, Mao F, Zeng S, Chen S, Zhao C, Gu M, Li Z, Fu X, Luo X, Huang Y. Central Hypoventilation Is a Key Risk Factor for Mechanical Ventilation During the Acute Phase of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Front Neurol 2021; 12:728594. [PMID: 34795627 PMCID: PMC8594565 DOI: 10.3389/fneur.2021.728594] [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] [Received: 06/21/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an acute form of encephalitis of autoimmune etiology. We aimed to evaluate the risk factors that predicted the need for mechanical ventilation during the acute phase of anti-NMDAR encephalitis through an analysis of the clinical characteristics and biochemical test results of the patients with anti-NMDAR encephalitis. Methods: In this retrospective study, patients who primarily presented with anti-NMDAR encephalitis and exhibited anti-NMDAR antibody positivity in the cerebrospinal fluid (CSF) between November 2015 and February 2020 were included. Data on the clinical characteristics, biochemical test results, and treatment methods selected for the patients were collected for the analysis of factors predicting the need for mechanical ventilation. Results: Thirty-one patients with a median age of onset of 31 years (inter-quartile range: 21–48 years) were included in this study, of which 15 were male (48.4%). Psychosis (23, 74.2%), seizures (20, 64.5%), and memory deficit (20, 64.5%) were the most common clinical manifestations. At admission, 17 patients (54.8%) presented with pyrexia, of which 12 (38.7%) had a body temperature ≥38°C, and six patients (19.4%) presented with central hypoventilation. All patients received first-line therapy (glucocorticoids, intravenous immunoglobulin, or plasmapheresis alone or combined), whereas two patients (6.5%) received rituximab, a second-line agent, as well. Seven patents required mechanical ventilation. Results of univariate logistic regression analysis revealed that body temperature ≥38°C [odds ratio (OR) = 18, 95% confidence interval (CI): 1.79–181.31, P < 0.05] and central hypoventilation at admission (OR = 57.50, 95% CI: 4.32–764.89, P < 0.05) were the risk factors for mechanical ventilation. Multivariate logistic regression analysis showed that central hypoventilation at admission was the only risk factor predicting the need for mechanical ventilation. Conclusion: Central hypoventilation at admission is a key risk factor for mechanical ventilation during hospitalization in patients with anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Qianhui Xu
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Qian Wang
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Jing Han
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Fengju Mao
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Silin Zeng
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Siyan Chen
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Chenyong Zhao
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Mei Gu
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Zaiwang Li
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Xuejun Fu
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Xiaoguang Luo
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Ying Huang
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| |
Collapse
|
27
|
Gomez-Figueroa E, Garcia-Estrada C, Paredes-Aragon E, Salado-Burbano J, Cortés-Enriquez F, Marrufo-Melendez O, Espinola-Nadurille M, Ramirez-Bermudez J, Rivas-Alonso V, Corona T, Flores-Rivera J. Brain MRI volumetric changes in the follow-up of patients with anti-NMDAr encephalitis. Clin Neurol Neurosurg 2021; 209:106908. [PMID: 34488009 DOI: 10.1016/j.clineuro.2021.106908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 08/09/2021] [Accepted: 08/18/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Autoimmune anti-NMDAr encephalitis is an antibody-mediated disorder characterized by psychiatric symptoms followed by decreased consciousness, dysautonomia and seizures. The pathophysiology of the disease is related to the internalization of NR1 subtype NMDA receptors and the dysfunction of structures where they are abundant (frontotemporal and insular regions). Some reports suggest the existence of cerebral atrophy in the follow-up of these patients, with conflicting evidence regarding its presence and usefulness as a marker of prognosis. METHODS In a longitudinal, observational study, all patients with the diagnosis of definite anti-NMDAr autoimmune encephalitis with initial and control MRI studies were included. Conventional MR Brain acquisition was performed using a 3-Tesla Skyra MRI System. Automated brain segmental analysis was performed using the Volbrain volumetry system. The differences between baseline MRI volumetric characteristics and volumetric measures at follow-up was assessed. RESULTS 25 patients were included (mean age 26.6, SD 9.6). 44% were females. The mean time between the studies was 24 (SD 21.4, 3-24) months. Significant volume loss was identified in the total brain volume (- 0.02%, p = 0.029), cerebellar volume (- 0.27%, p = 0.048) and brainstem volume (- 0.16%, p = 0.021). CONCLUSIONS This study supports previous observations regarding volume loss in several brain regions of patients with antiNMDAr encephalitis. Further analyses are required to understand the role of treatment and severe clinical forms, as well as the relationship between volume loss and functional outcome.
Collapse
Affiliation(s)
- Enrique Gomez-Figueroa
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico.
| | | | - Elma Paredes-Aragon
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | | | | | - Oscar Marrufo-Melendez
- Neuroimaging Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | | | - Jesus Ramirez-Bermudez
- Neuropsychiatry Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - Verónica Rivas-Alonso
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - Teresita Corona
- Neurodegenerative Diseases Laboratory, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| | - José Flores-Rivera
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía, México City, Mexico
| |
Collapse
|
28
|
|
29
|
Datta AK, Pandit A, Biswas S, Biswas A, Roy BK, Gangopaddhyay G. Spectrum of Anti-NMDA Receptor Antibody Encephalitis: Clinical Profile, Management and Outcomes. Ann Indian Acad Neurol 2021; 24:383-389. [PMID: 34447002 PMCID: PMC8370154 DOI: 10.4103/aian.aian_817_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/02/2020] [Accepted: 10/14/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Anti-N-methyl D-aspartate receptor (anti NMDAR) antibody encephalitis is an immune-mediated entity characterised by a constellation of neuro-psychiatric symptoms. Objective: To describe clinical profile and treatment outcomes of patients with anti NMDAR antibody encephalitis. Settings and Design: Subjects were selected by screening for all patients satisfying Graus et al.'s criteria for probable anti NMDAR antibody encephalitis, admitted in neurology department of a tertiary care centre in Eastern India. Materials and Methods: A prospective, longitudinal study was conducted by identifying 25 patients with anti NMDAR antibodies in CSF and or serum, between September 2018 to February 2020. Statistical Analysis: Chi square test was used to compare variables. Results: Out of 98 patients screened, 25 subjects (14 females: 11 male) were positive for anti NMDAR autoantibodies, with a mean age of 17 years. 13 subjects belonged to paediatric age group. Most common presenting feature was memory/learning deficit (88%) followed by behavioural abnormalities (84%) and seizures (68%). 11 patients (44%) patients needed escalation to second line therapy, rituximab. Seven (28%) and twelve (48%) patients underwent complete (mRS 0-1) and partial recovery (mRS 2-3) respectively, while 4 (16%) became disabled (mRS 4-5). Mortality was 8%. Paediatric population had a better outcome in terms of disability (p = 0.043). Conclusion: Anti NMDAR-Ab encephalitis is the most common cause of antibody positive autoimmune encephalitis worldwide. There are important clinical markers and investigational profiles which carry prognostic significance.
Collapse
Affiliation(s)
- Amlan Kusum Datta
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Samar Biswas
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Atanu Biswas
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Biman Kanti Roy
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| | - Goutam Gangopaddhyay
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research, Annex 1, Gokhel Road, Bhowanipore, Kolkata, West Bengal, India
| |
Collapse
|
30
|
Chen L, Zhu L, Lu D, Dai S, Han Y, Wu Z, Xu P, Chang L, Wu Q. Association between autoimmune encephalitis and epilepsy: Systematic review and meta-analysis. Seizure 2021; 91:346-359. [PMID: 34284303 DOI: 10.1016/j.seizure.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/04/2021] [Accepted: 07/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diverse neuronal antibodies are related to autoimmune encephalitis (AE) and AE-related epilepsy. However, the epidemiological characteristics of AE, AE-associated antibodies, and AE-related seizures are still unclear. AIMS This research evaluated the relationship between AE, AE-related seizures, and neuronal antibodies, as well as the morbidity of AE with early incidence. METHODS The PubMed, Embase, Cochrane, and Web of Science databases were searched. Pooled estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. RESULTS Of the 4,869 citations identified, 100 articles were reviewed in full, and 42 subgroups were analyzed. The overall incidence of AE patients with seizures was 42% (95% CI: 0.40-0.44), and among them, the incidence of epilepsy in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients was 73% (95% CI: 0.70-0.77). Subsequently, we found that the prevalence of AE as the cause of epilepsy within the pooled period was 1% (95% CI: 0.01-0.02), while the overall positive rate of neuronal antibodies in epilepsy patients was 4% (95% CI: 0.03-0.05). Additionally, the detection rates of different antibodies among epilepsy patients were as follows: anti-NMDAR, 1%; anti-leucine-rich glioma inactivated 1 (LGI1), 1%; anti-contactin-associated protein-like 2 (CASPR2), 2%. CONCLUSION Based on our findings, neuronal antibodies may serve as a bridge to study AE and immune-related epilepsy. To further understand the differences in outcomes following different treatment measures, and to provide more information for public health policy and prevention, more research is needed to improve the accuracy of estimations.
Collapse
Affiliation(s)
- Lu Chen
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Lin Zhu
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Di Lu
- Biomedicine Engineering Research Centre, Kunming Medical University, 1168 Chun Rong West Road, Kunming, Yunnan 650032, PR China
| | - Shujuan Dai
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Yanbing Han
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Zhe Wu
- Department of Psychology, The First People's Hospital of Yunnan Province, 157 Jin Bi Road, Kunming, Yunnan 650100, PR China
| | - Puying Xu
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Lvhua Chang
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China
| | - Qian Wu
- Department of Neurology, First Affiliated Hospital, Kunming Medical University, 295 Xi Chang Road, Kunming, Yunnan 650032, PR China.
| |
Collapse
|
31
|
Li TR, Zhang YD, Wang Q, Shao XQ, Lyu DY, Lv RJ. Clinical Characteristics and Long-Term Prognosis of Anti-LGI1 Encephalitis: A Single-Center Cohort Study in Beijing, China. Front Neurol 2021; 12:674368. [PMID: 34168612 PMCID: PMC8217831 DOI: 10.3389/fneur.2021.674368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background: This study aimed to analyze the clinical characteristics of anti-leucine-rich glioma-inactivated protein 1 (LGI1) encephalitis patients and investigate prognostic factors by using a large-sample and long-term follow-up cohort. Methods: The clinical data of 45 patients (29 males; mean age, 57.0 years) from May 2014 to August 2019 were collected. All patients were followed up by face-to-face interviews in the third month after discharge and then by telephone and/or face-to-face interviews every 6 months until November 2020. We evaluated each patient's response to the initial treatments at the first interview and divided them into “responders” and “nonresponders.” Relapses were recorded. At the end of follow-up, each patient was evaluated and reclassified into “complete recovery” or “unhealed” groups. Intergroup differences were assessed. Results: All patients presented with seizures at the initial consultation. Other common manifestations included cognitive dysfunction (82.2%), psychiatric disturbance (66.7%), sleep disorder (54.5%), and hyponatremia (66.7%). During the follow-up period (32.8 ± 13.5 months), six patients experienced relapse within 6–37 months. We observed that the patients who did not respond to the initial treatments and those who relapsed all had a poor long-term prognosis. The patients in the “unhealed” group were older (p = 0.009), had a lower incidence of generalized tonic–clonic seizures (p = 0.041), and had a higher probability of cerebrospinal fluid (CSF) abnormalities (p = 0.024) than those in the “complete recovery” group. Conclusion: Anti-LGI1 encephalitis was characterized by seizures, cognitive impairment, psychiatric disturbance, and sleep disorders and was often accompanied by hyponatremia. Patients who responded poorly to the initial treatments and those patients who relapsed had dismal long-term prognoses. Advanced age and CSF abnormalities may be risk factors for poor prognosis, but these still need to be verified.
Collapse
Affiliation(s)
- Tao-Ran Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yu-Di Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, The Second Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Di-Yang Lyu
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China
| |
Collapse
|
32
|
Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. A Validated Nomogram That Predicts Prognosis of Autoimmune Encephalitis: A Multicenter Study in China. Front Neurol 2021; 12:612569. [PMID: 33897585 PMCID: PMC8060553 DOI: 10.3389/fneur.2021.612569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/08/2021] [Indexed: 12/03/2022] Open
Abstract
The aim of this retrospective study was to derive and validate a reliable nomogram for predicting prognosis of autoimmune encephalitis (AE). A multi-center retrospective study was conducted in four hospitals in China, using a random split-sample method to allocate 173 patients into either a training (n = 126) or validation (n = 47) dataset. Demographic, radiographic and therapeutic presentation, combined with clinical features were collected. A modified Rankin Scale (mRS) at discharge was the principal outcome variable. A backward-stepwise approach based on the Akaike information criterion was used to test predictors and construct the final, parsimonious model. Multivariable analysis was conducted using logistic regression to develop a prognosis model and validate a nomogram using an independent dataset. The performance of the model was assessed using receiver operating characteristic curves and a Hosmer-Lemeshow test. The final nomogram model considered age, viral prodrome, consciousness impairment, memory dysfunction and autonomic dysfunction as predictors. Model validations displayed a good level of discrimination in the validation set: area under the Receiver operator characteristic curve = 0.72 (95% Confidence Interval: 0.56–0.88), Hosmer–Lemeshow analysis suggesting good calibration (chi-square: 10.33; p = 0.41). The proposed nomogram demonstrated considerable potential for clinical utility in prediction of prognosis in autoimmune encephalitis.
Collapse
Affiliation(s)
- Yueqian Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guoping Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiong Han
- Department of Neurology, Henan Provincial People's Hospital, Henan, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Tiancheng Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neuromodulation, Beijing, China
| |
Collapse
|
33
|
Hayden Z, Bóné B, Orsi G, Szots M, Nagy F, Csépány T, Mezei Z, Rajda C, Simon D, Najbauer J, Illes Z, Berki T. Clinical Characteristics and Outcome of Neuronal Surface Antibody-Mediated Autoimmune Encephalitis Patients in a National Cohort. Front Neurol 2021; 12:611597. [PMID: 33767656 PMCID: PMC7985080 DOI: 10.3389/fneur.2021.611597] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/16/2021] [Indexed: 01/15/2023] Open
Abstract
Background: In our previous single-center study of autoimmune encephalitis (AE) related autoantibody test results we found positivity in 60 patients out of 1,034 with suspected AE from 2012 through 2018 as part of a Hungarian nationwide program. In our current multicenter retrospective study, we analyzed the clinical characteristics and outcome of AE patients with positive neuronal cell surface autoantibody test results. Methods: A standard online questionnaire was used to collect demographic and clinical characteristics, laboratory and imaging data, therapy and prognosis of 30 definitive AE patients in four major clinical centers of the region. Results: In our study, 19 patients were positive for anti-NMDAR (63%), 6 patients (20%) for anti-LGI1, 3 patients for anti-GABABR (10%) and 3 patients for anti-Caspr2 (10%) autoantibodies. Most common prodromal symptoms were fever or flu-like symptoms (10/30, 33%). Main clinical features included psychiatric symptoms (83%), epileptic seizures (73%) and memory loss (50%). 19 patients (63%) presented with signs of central nervous system (CNS) inflammation, which occurred more frequently in elder individuals (p = 0.024), although no significant differences were observed in sex, tumor association, time to diagnosis, prognosis and immunotherapy compared to AE patients without CNS inflammatory markers. Anti-NMDAR encephalitis patients were in more severe condition at the disease onset (p = 0.028), although no significant correlation between mRS score, age, sex and immunotherapy was found. 27% of patients (n = 8) with associated tumors had worse outcome (p = 0.045) than patients without tumor. In most cases, immunotherapy led to clinical improvement of AE patients (80%) who achieved a good outcome (mRS ≤ 2; median follow-up 33 months). Conclusion: Our study confirms previous publications describing characteristics of AE patients, however, differences were observed in anti-NMDAR encephalitis that showed no association with ovarian teratoma and occurred more frequently among young males. One-third of AE patients lacked signs of inflammation in both CSF and brain MRI, which emphasizes the importance of clinical symptoms and autoantibody testing in diagnostic workflow for early introduction of immunotherapy, which can lead to favorable outcome in AE patients.
Collapse
Affiliation(s)
- Zsófia Hayden
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Beáta Bóné
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Gergely Orsi
- MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary.,Department of Neurosurgery, Clinical Centre, University of Pécs Medical School, Pécs, Hungary
| | - Monika Szots
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Nagy
- Department of Neurology, Somogy County Kaposi Mór University Teaching Hospital, Kaposvár, Hungary
| | - Tünde Csépány
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Zsolt Mezei
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Cecília Rajda
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Diána Simon
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - József Najbauer
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, BRIDGE, University of Southern Denmark, Odense, Denmark
| | - Timea Berki
- Department of Immunology and Biotechnology, Clinical Center, University of Pécs Medical School, Pécs, Hungary
| |
Collapse
|
34
|
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.
Collapse
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.
| |
Collapse
|
35
|
Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. The Association Between Age and Prognosis in Patients Under 45 Years of Age With Anti-NMDA Receptor Encephalitis. Front Neurol 2021; 11:612632. [PMID: 33447251 PMCID: PMC7802749 DOI: 10.3389/fneur.2020.612632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Abstract
This study aims to evaluate the association between age and prognosis in patients with anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) under the age of 45 years. A retrospective study was conducted in patients younger than 45 years diagnosed as anti-NMDARE in four hospitals in China. Age at admission was divided into four categories: <15, 15–24, 25–34, 35–45 years. Neurological prognosis was evaluated using modified Rankin Scale. Adjusted multivariable logistic regression was used to analyze the association. The multivariable-adjusted odds ratios (95% confidence interval) of prognosis in anti-NMDARE across the categories of age were as follows: in males, 1.00 (reference), 4.76 (0.39–58.76), 13.50 (0.79–230.40), and 8.81 (0.36–218.39) (P for trend = 0.171); in females, 1.00 (reference), 7.27 (0.36–146.19), 20.08 (1.09–370.39), and 54.41 (1.60–1,849.10) (P for trend = 0.01). We concluded that the increasing age was associated with a poorer prognosis of anti-NMDARE in females but not males.
Collapse
Affiliation(s)
- Yueqian Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guoping Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Xiong Han
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tiancheng Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| |
Collapse
|
36
|
Diagnostic Value of Structural and Functional Neuroimaging in Autoimmune Epilepsy. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:8894213. [PMID: 33380947 PMCID: PMC7752299 DOI: 10.1155/2020/8894213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/15/2023]
Abstract
Epilepsy is a common nervous system disease, which affects about 70 million people all over the world. In 2017, the International League Against Epilepsy (ILAE) considered immune factors as its independent cause, and the concept of autoimmune epilepsy (AE) was widely accepted. Early diagnosis and timely treatment can effectively improve the prognosis of the disease. However, due to the diversity of clinical manifestations, the expensive cost of autoantibody detection, and the increased prevalence in Western China, the difficulty for clinicians in early diagnosis and treatment has increased. Fortunately, convenient and fast imaging examinations are expected to help even more. The imaging manifestations of AE patients were characteristic, especially the combined application of structural and functional neuroimaging, which improved the diagnostic value of imaging. In this paper, several common autoantibodies associated with AE and their structure and function changes in neuroimaging were reviewed to provide help for neurologists to achieve the goal of precision medicine.
Collapse
|
37
|
Dou X, Li D, Wu Y, Wang Z, Yang L, Ma N, Wang D, Li X. Efficacy and Safety of Rituximab in Chinese Children With Refractory Anti-NMDAR Encephalitis. Front Neurol 2020; 11:606923. [PMID: 33381080 PMCID: PMC7767921 DOI: 10.3389/fneur.2020.606923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/24/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose: To assess the efficacy and safety of rituximab treatment as second-line immunotherapy in pediatric cases of anti-NMDA receptor (NMDAR) encephalitis. Methods: We retrospectively recruited 8 patients with anti-NMDAR encephalitis who were treated with rituximab as second-line immunotherapy. We evaluated the clinical features, laboratory examination results and treatment protocols of the Chinese children and defined good outcomes based on the modified Rankin scale (mRS) score (0-2) at the last follow-up. Results: A total of eight pediatric patients (median age 6.7 years; four female) with refractory anti-NMDAR encephalitis were recruited to the study. Rituximab was given after a median duration of disease of 57 days (range 50.5-113.75 days). The use of rituximab led to a significant reduction in the mRS and CD19+ B-cells compared to before rituximab infusion (P < 0.05). Five patients (62.5%) had a good outcome (mRS ≤ 2) including four patients (50%) who showed complete recovery (mRS = 0) at the last follow-up. Transient infusion adverse events were recorded in 2 patients (25%). Two patients (25%) had severe infectious adverse events (AEs) and two patients with grade 5 (death). None of the patients developed progressive multifocal leukoencephalopathy (PML). Conclusion: Our study provides evidence that rituximab can efficiently improve the clinical symptoms of anti-NMDAR encephalitis in children. However, due to the risk of adverse infections, rituximab should be restricted in pediatric patients with high rates of mortality and disability.
Collapse
Affiliation(s)
- Xiangjun Dou
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Dongjing Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Yan Wu
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Zhijing Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Le Yang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Nan Ma
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Dong Wang
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| | - Xia Li
- Department of Pediatric Neurology, Xi'an Children' Hospital, Xi'an, China
| |
Collapse
|
38
|
Yu Y, Wu Y, Cao X, Li J, Liao X, Wei J, Huang W. The Clinical Features and Prognosis of Anti-NMDAR Encephalitis Depends on Blood Brain Barrier Integrity. Mult Scler Relat Disord 2020; 47:102604. [PMID: 33130468 DOI: 10.1016/j.msard.2020.102604] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/04/2020] [Accepted: 10/25/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune nervous system disease that has become increasingly recognized. This retrospective study is aimed to analyze the relations between clinical manifestations and blood brain barrier (BBB) integrity in anti-NMDAR encephalitis patients. METHODS Anti-NMDAR encephalitis patients were admitted to the First Affiliated Hospital of Guangxi Medical University from April 2014 to April 2020. Patients were grouped by the normal BBB and damaged BBB groups according to the cerebrospinal fluid (CSF) albumin/serum albumin (QAlb). Neutrophil-to-lymphocyte ratio (NLR) in peripheral blood was used for estimating the inflammatory status. The modified Rankin Scale (mRS) was used to assess prognosis. RESULTS Seventy-three anti-NMDAR encephalitis patients were diagnosed based on the autoimmune encephalitis diagnosis criteria of 2016. Fifty-three (72.6%) patients were in the normal BBB group and twenty (27.4%) were in the BBB damaged group. There were no significant differences in gender, age, psychiatric disturbances, epilepsy, speech disorder, motor dysfunction, memory dysfunction, and autonomic dysfunction between the two groups (p>0.05). Nevertheless, the proportions of decreased consciousness, ICU admission, NLR, CSF protein and intrathecal IgG synthesis (IgGIF, IgGLoc) in the damaged BBB group were higher than that in the normal BBB group (p<0.05). Patients (79.2%) with normal BBB had good prognosis compared to patients with damaged BBB (50%) after 2 months follow-up. The median mRS before and after immunotherapy in the damaged BBB group were significantly higher than that in the normal BBB group (p<0.01, p<0.05, respectively). Additionally, QAlb increased was positively correlated with the quantitative intrathecal IgG synthesis (IgGLoc: r=0.66; IgGIF: r=0.433, all p<0.001). CONCLUSION The dysfunction of BBB can be helpful in evaluating its prognosis since QAlb showed associations with ICU admission, NLR, a higher CSF protein, intrathecal IgG synthesis (IgGLoc, IgGIF) and mRS score after 2 months follow-up.
Collapse
Affiliation(s)
- Yachun Yu
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Yu Wu
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Xiaoli Cao
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Jing Li
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Xiangling Liao
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Junxiang Wei
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021
| | - Wen Huang
- Department of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, P. R. China, 530021.
| |
Collapse
|
39
|
Li A, Gong X, Guo K, Lin J, Zhou D, Hong Z. Direct economic burden of patients with autoimmune encephalitis in western China. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/6/e891. [PMID: 33008922 PMCID: PMC7577530 DOI: 10.1212/nxi.0000000000000891] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/19/2020] [Indexed: 01/17/2023]
Abstract
Objective To analyze the cost of autoimmune encephalitis (AE) in China for the first time. Methods Patients who were newly diagnosed with antibody-positive AE (anti-NMDA receptor [NMDAR], anti-γ aminobutyric acid type B receptor [GABABR], antileucine-rich glioma-inactivated 1 [LGI1], and anticontactin-associated protein-2 [CASPR2]) at West China Medical Center between June 2012 and December 2018 were enrolled, and a cost-of-illness study was performed retrospectively. Data on clinical characteristics, costs, and utilization of sources were collected from questionnaires and the hospital information system. Results Of the 208 patients reviewed, the mean direct cost per patient was renminbi (RMB) 94,129 (United States dollars [USD] 14,219), with an average direct medical cost of RMB 88,373 (USD 13,349). The average inpatient cost per patients with AE was RMB 86,810 (USD 13,113). The direct nonmedical cost was much lower than the direct medical cost, averaging RMB 5,756 (USD 869). The direct cost of anti-LGI1/CASPR2 encephalitis was significantly lower than that of anti-NMDAR encephalitis and anti-GABABR encephalitis. The length of stay in the hospital was significantly associated with the direct cost. Conclusions The financial burden of AE is heavy for Chinese patients, and there are significant differences between different types of AE.
Collapse
Affiliation(s)
- Aiqing Li
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu.
| | - Xue Gong
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Kundian Guo
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Jingfang Lin
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Dong Zhou
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu
| | - Zhen Hong
- From the Department of Neurology, West China Medical Center, Sichuan University, Chengdu.
| |
Collapse
|
40
|
Jiang XY, Lei S, Zhang L, Liu X, Lin MT, Blumcke I, Piao YS, Zhou D, Li JM. Co-expression of NMDA-receptor subunits NR1, NR2A, and NR2B in dysplastic neurons of teratomas in patients with paraneoplastic NMDA-receptor-encephalitis: a retrospective clinico-pathology study of 159 patients. Acta Neuropathol Commun 2020; 8:130. [PMID: 32771066 PMCID: PMC7414584 DOI: 10.1186/s40478-020-00999-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023] Open
Abstract
Objective To comprehensively describe the pathological features of neurons in patients with ovarian teratomas and paraneoplastic anti-NMDAR encephalitis (anti-NMDARE), emphasizing on NMDA-receptor expression and infiltrating lymphocytes. Methods A retrospective study was performed in a large series of 159 patients from the West China Hospital. We retrospectively identified 12 patients with paraneoplastic anti-NMDARE (11 case with ovarian teratomas and 1 case with mixed germ cell tumor), which were compared to 35 patients with teratomas and no encephalitis and to 147 patients with anti-NMDARE and no evidence for tumors. Patient history and outcome were reviewed from the clinical charts and compared between all three groups. Histopathological examination, including double-immunofluorescence of NMDAR subunits and IgG was performed in all teratoma tissues. Magnetic Luminex Assay Human Premixed Multi-Analyte Kit was performed to investigate cytokines profile of CSF. Results Patients with paraneoplastic anti-NMDARE had a more severe clinical presentation, i.e. they required more mechanical ventilation and intensive care (p < 0.001). Though immunotherapy was initiated earlier in this group, repeated intravenous immunoglobulin administration (IVIG) was more common (p = 0.002) and with higher cerebrospinal fluid (CSF) antibody titres (p = 0.004). Following tumor resection, the outcome did not differ between groups. A peculiar population of floating-frog like dysplastic neurons were observed only in teratomas of patients with paraneoplastic anti-NMDARE, co-expressing NR1, NR2A, NR2B subunits and IgG. Also, CD20 positive B-cells were more common in anti-NMDARE teratomas. In CSF of paraneoplastic anti-NMDARE patients, TNF-α, IL-10 and GM-CSF concentrations were higher than in negative symptom control and VEGF-A and IL-1a were lower than in anti-NMDARE patients (0.25 < p < 0.05). Conclusions Patients with teratomas and paraneoplastic anti-NMDARE revealed a cellular population of dysplastic neurons co-expressing NMDAR subunits, which were the potential source of autoantigens triggering anti-NMDARE. Some inflammatory cytokines may be involved in pathogenesis of paraneoplastic anti-NMDARE.
Collapse
|
41
|
Peng Y, Dai F, Liu L, Chen W, Yan H, Liu A, Zhang X, Wang X, He J, Li Y, Li C, Chen L, Zhao Y, Li L, Ma Q, Wang J. Validation of the NEOS score in Chinese patients with anti-NMDAR encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/5/e860. [PMID: 32759178 PMCID: PMC7413709 DOI: 10.1212/nxi.0000000000000860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/29/2020] [Indexed: 12/25/2022]
Abstract
Objective The performance of anti-NMDAR Encephalitis One-Year Functional Status (NEOS) in predicting the 1-year functional status in Chinese patients with anti-NMDAR encephalitis is unknown. Methods We recruited patients with anti-NMDAR encephalitis from the Multicenter and Prospective Clinical Registry Study of Anti-NMDAR Encephalitis in Beijing Area. Patients were followed up for 1 year. We defined the poor functional status as a modified Rankin Scale score of more than 2 and good functional status as a modified Rankin Scale score of no more than 2. We performed a receiver-operator characteristic analysis to assess the discriminatory power of the NEOS score in predicting the 1-year functional status by using the area under the curve (AUC). Calibration was assessed by Pearson correlation coefficient and Hosmer-Lemeshow tests. Results Among the 111 patients with anti-NMDAR encephalitis recruited from 364 potentially eligible participants, 87 (78.4%) had good functional status at 1 year, whereas the remaining 24 (21.6%) had poor functional status. The AUC of the NEOS score for 1-year poor functional status was 0.86 (95% CI 0.78–0.93, p < 0.001). The increased NEOS was associated with higher risk of 1-year poor functional status in patients with anti-NMDAR encephalitis. Conclusions The NEOS score is considered a reliable predictor of the risk of 1-year poor functional status in Chinese patients with anti-NMDAR encephalitis. This score could help to estimate the velocity of clinical improvement in advance. Clinicaltrial.gov identifier NCT02443350. Classification of evidence This study provides Class III evidence that in patients with anti-NMDAR encephalitis, the NEOS score predicts 1-year functional status.
Collapse
Affiliation(s)
- Yujing Peng
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Feifei Dai
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Lei Liu
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Weiqi Chen
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Hongyi Yan
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Aihua Liu
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Xinghu Zhang
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Xiaohui Wang
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China.
| | - Junying He
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Yatong Li
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Chenxi Li
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Liuxi Chen
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Yan Zhao
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Lin Li
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Qiuying Ma
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China
| | - Jiawei Wang
- From the Department of Neurology, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Medical Research Center, Beijing Tong Ren Hospital, Capital Medical University (Y.P., F.D., L. Liu, Y.L., C.L., L.C., Y.Z., L. Li, Q.M., J.W.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University (W.C., H.Y., X.Z.); Department of Neurology, Xuanwu Hospital, Capital Medical University (A.L.), Beijing; Beijing Children Hospital, Capital Medical University (X.W.); Department of Neurology, the Second Hospital of Hebei Medical University (J.H.), Shijiazhuang; China National Clinical Research Center for Neurological Diseases (W.C., H.Y.), Beijing; Center of Stroke, Beijing Institute for Brain Disorders (W.C., H.Y.); and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (W.C., H.Y.), China.
| |
Collapse
|
42
|
Abstract
PURPOSE OF REVIEW To review sleep complaints reported in patients with autoimmune encephalitis, explore the relationship between sleep disturbances and subtypes of autoimmune encephalitis, and leverage knowledge concerning antibody-antigen specificity to inform the receptors, structures, and disseminated neural networks that contribute to sleep function in health and disease. RECENT FINDINGS Autoimmune encephalitis is an inflammatory brain disorder characterized by the subacute onset of psychiatric symptoms, cognitive impairment, and focal neurologic deficits or seizures. Sleep disturbances are detected in a majority of patients systematically screened for sleep complaints, may be the presenting symptom in patients with autoimmune encephalitis, and may compromise recovery in patients with autoimmune encephalitis. Early recognition of specific sleep disturbances in patients with subacute changes in behavior or cognition may support the diagnosis of autoimmune encephalitis. Similarly, recognition and treatment of sleep dysfunction in patients with known autoimmune encephalitis may speed recovery and improve long-term outcomes.
Collapse
Affiliation(s)
- Margaret S Blattner
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, USA.
| |
Collapse
|
43
|
Hébert J, Gros P, Lapointe S, Amtashar FS, Steriade C, Maurice C, Wennberg RA, Day GS, Tang-Wai DF. Searching for autoimmune encephalitis: Beware of normal CSF. J Neuroimmunol 2020; 345:577285. [PMID: 32563126 DOI: 10.1016/j.jneuroim.2020.577285] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/17/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the prevalence of cerebrospinal fluid (CSF) markers associated with inflammation (i.e., elevated white blood cell count, protein concentration, and CSF-specific oligoclonal bands) in patients with early active autoimmune encephalitis (AE). METHODS CSF characteristics, including WBC count, protein concentration, and oligoclonal banding, were analyzed in patients diagnosed with AE at two tertiary care centers. RESULTS Ninety-five patients were included in the study. CSF white blood cell counts and protein levels were within normal limits for 27% (CI95%: 19-37) of patients with AE. When results of oligoclonal banding were added, 14% (CI95%: 6-16) of patients with AE had "normal" CSF. The median CSF white blood cell count was 8 cells/mm3 (range: 0-544) and the median CSF protein concentration was 0.42 g/L (range: 0.15-3.92). CONCLUSIONS White blood cell counts and protein levels were within normal limits in the CSF of a substantial proportion of patients with early active AE. Inclusion of CSF oligoclonal banding identified a higher proportion of patients with an inflammatory CSF profile, especially when CSF was sampled early in the disease process.
Collapse
Affiliation(s)
- Julien Hébert
- University of Toronto, Division of Neurology, Canada
| | - Priti Gros
- University of Toronto, Division of Neurology, Canada
| | - Sarah Lapointe
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Fatima S Amtashar
- Washington University School of Medicine, Dept of Neurology, MO, USA
| | - Claude Steriade
- New York University Langone Comprehensive Epilepsy Center, NY, USA
| | - Catherine Maurice
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Richard A Wennberg
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada
| | - Gregory S Day
- Mayo Clinic Florida, Department of Neurology, Jacksonville, FL, USA
| | - David F Tang-Wai
- University of Toronto, Division of Neurology, Canada; University Health Network, Toronto, Canada.
| |
Collapse
|
44
|
Current Progress on Assessing the Prognosis for Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7506590. [PMID: 32352007 PMCID: PMC7178504 DOI: 10.1155/2020/7506590] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/01/2020] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most common antineuronal antibody encephalitis in autoimmune encephalitis found at present. It has complex clinical manifestations such as psychiatric and behavioral abnormalities, seizures, movement disorders, consciousness, and autonomic dysfunction. The relationship between those manifestations and prognosis is unclear. Electroencephalography (EEG) is gradually becoming useful in the evaluation of the prognosis of anti-NMDAR encephalitis patients, while imaging and antibody testing have a limited prognostic value. Starting the patients on adequate treatments (such as immunotherapy) in a timely fashion has a positive impact on their prognosis. Nevertheless, research on the prognosis of anti-NMDAR encephalitis remains scarce. Here, we review the current advances of prognosis-related research from the clinical manifestations of the disease and auxiliary examinations such as EEG, magnetic resonance imaging (MRI), 18F fluorodeoxyglucose positron emission tomography (FDG-PET), and antibody measurement. In addition, we also discuss the impact of different treatment options on prognosis. In-depth research on the prognosis of patients with anti-NMDAR encephalitis will contribute to a better understanding of this disease, leading to better treatments options and, ultimately, a better prognosis.
Collapse
|
45
|
Wang W, Zhang L, Chi XS, He L, Zhou D, Li JM. Psychiatric Symptoms of Patients With Anti-NMDA Receptor Encephalitis. Front Neurol 2020; 10:1330. [PMID: 32038450 PMCID: PMC6993807 DOI: 10.3389/fneur.2019.01330] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Objective: We conducted this study to analyze the clinical characteristics of the psychiatric symptoms of patients with anti-NMDAR encephalitis. Methods: A retrospective study of anti-NMDAR encephalitis in China was performed. The clinical characteristics of the psychiatric symptoms, the relationship between the antibodies titers and clinical characteristics of patients with anti-NMDAR encephalitis were determined. Results: A total of 108 patients with a definitive diagnosis of anti-NMDAR encephalitis were included in this study. 103 patients (95%) developed one or several psychiatric symptoms. The comparison of the high titer group and the low titer group showed that more patients presented psychiatric symptoms as the initial symptom in the high titer group (P = 0.020), the prevalence of the symptoms such as depressive, catatonic, and central hypoventilation were also higher in the high titer group than the low titer group (P = 0.033, 0.031 and 0.006, respectively). Meanwhile, more patients received a combination treatment of IVIg and corticosteroids in the high titer group than the low titer group and patients in high titer group were prescript with anti-psychiatric drugs more often than the patients in low titer group (P = 0.026 and 0.003, respectively). Conclusions: Psychiatric symptoms are the most common clinical characteristics of patients with anti-NMDAR encephalitis. Patients with higher antibodies titers more often presented with psychiatric symptoms as the initial symptom, and showed a more severe clinical feature. Screening for the anti-NMDAR antibodies is essentially important in patients who present psychiatric symptoms with or without other neurological symptoms.
Collapse
Affiliation(s)
- Wei Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Le Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Sa Chi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
46
|
Mo Y, Wang L, Zhu L, Li F, Yu G, Luo Y, Ni M. Analysis of Risk Factors for a Poor Prognosis in Patients with Anti- N-Methyl-D-Aspartate Receptor Encephalitis and Construction of a Prognostic Composite Score. J Clin Neurol 2020; 16:438-447. [PMID: 32657065 PMCID: PMC7354980 DOI: 10.3988/jcn.2020.16.3.438] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most-common form of autoimmune encephalitis, but its early diagnosis is challenging. This study aimed to identify the risk factors for a poor prognosis in anti-NMDAR encephalitis and construct a prognostic composite score for obtaining earlier predictions of a poor prognosis. METHODS We retrospectively analyzed the clinical data, laboratory indexes, imaging findings, and electroencephalogram (EEG) data of 60 patients with anti-NMDAR encephalitis. The modified Rankin Scale (mRS) scores of patients were collected when they were discharged from the hospital. The mRS scores were used to divide the patients into two groups, with mRS scores of 3-6 defined as a poor prognosis. Logistic regression analysis was used to analyze independent risk factors related to a poor prognosis. RESULTS This study found that 23 (38.3%) and 37 (61.7%) patients had good and poor prognoses, respectively. Logistic regression analysis showed that age, disturbance of consciousness at admission, and ≥50% slow waves on the EEG were significantly associated with patient outcomes. An age, consciousness, and slow waves (ACS) composite score was constructed to predict the prognosis of patients with anti-NMDAR encephalitis at an early stage based on regression coefficients. CONCLUSIONS Age, disturbance of consciousness at admission, and ≥50% slow waves on the EEG were independent risk factors for a poor prognosis. The ACS prognostic composite score could play a role in facilitating early predictions of the prognosis of anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Yejia Mo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Li Wang
- Department of Biology and Biochemistry, Center for Nuclear Receptors and Cell Signaling, University of Houston, Houston, TX, USA
| | - Libo Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Gang Yu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Yetao Luo
- Department of Biostatistics, School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Meng Ni
- Department of the First Clinical Medicine, Chongqing Medical University, Chongqing, China
| |
Collapse
|
47
|
Gong X, Liu X, Li C, Chen C, Lin J, Li A, An D, Zhou D, Hong Z. Reply: Gut microbiome alterations in anti-NMDA receptor encephalitis: caveats for result interpretation. Ann Clin Transl Neurol 2019; 7:155-156. [PMID: 31880077 PMCID: PMC6952304 DOI: 10.1002/acn3.50969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xue Gong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Chen Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Chu Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Aiqing Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Dongmei An
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| |
Collapse
|
48
|
Zhang L, Lu Y, Xu L, Liu L, Wu X, Zhang Y, Zhu G, Hong Z. Anti-N-methyl-D-aspartate receptor encephalitis with accompanying ovarian teratoma in female patients from East China: Clinical features, treatment, and prognostic outcomes. Seizure 2019; 75:55-62. [PMID: 31874360 DOI: 10.1016/j.seizure.2019.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The association between anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR encephalitis) and teratoma is formally recognized. This study compared the clinical features, treatments and outcomes between female patients with or without accompanying teratomas and determined the potential influences of coexisting teratomas. METHOD Fifty-six female patients diagnosed with anti-NMDAR encephalitis were enrolled in two major tertiary hospitals in East China from January 2013 through March 2018 and were grouped as patients with or without teratoma. The clinical features were reviewed, and follow-up studies were performed. Comparisons were made between the two groups. RESULTS Patients with teratoma reported fewer viral prodromes (p = 0.0085) and stronger positive intensity of anti-NMDAR antibodies in cerebrospinal fluid (CSF) (p = 0.0368), while nontumor patients tended to demonstrate lymphocytic pleocytosis in CSF (p = 0.0306). Seizure types varied between individuals, with complex partial seizures more common in teratoma patients (p = 0.0105). Nontumor patients frequently required combinations of first-line and second-line immunotherapy (p = 0.0014), which may be attributed to higher mRS scores at admission (p = 0.0300). Also, they had higher mean mRS scores since the 12-month follow-up and greater probability of relapse than did patients with teratomas (p = 0.0286). CONCLUSIONS Symptomatology and auxiliary findings indicate that ovarian teratoma may be the immunologic trigger for anti-NMDAR encephalitis patients, while viral infection is likely to play a major part in pathogenesis for those without any detectable tumor. Overall, anti-NMDAR encephalitis patients with teratomas present with milder neurological symptoms and have better long-term outcomes after tumor removal.
Collapse
Affiliation(s)
- Lu Zhang
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Yao Lu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lan Xu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Lu Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Xunyi Wu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China.
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
| | - Guoxing Zhu
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhen Hong
- Department of Neurology at Huashan Hospital, Fudan University, Shanghai, 200032, China
| |
Collapse
|
49
|
Liu X, Zhang L, Chen C, Gong X, Lin J, An D, Zhou D, Hong Z. Long-term cognitive and neuropsychiatric outcomes in patients with anti-NMDAR encephalitis. Acta Neurol Scand 2019; 140:414-421. [PMID: 31483852 DOI: 10.1111/ane.13160] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/07/2019] [Accepted: 08/29/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the long-term cognitive or neuropsychiatric outcomes and potential risk factors associated with prolonged cognitive deficits or neuropsychiatric symptoms in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. METHODS In this cohort follow-up study, patients with a definitive diagnosis of anti-NMDAR encephalitis from the inpatient of West China Hospital between June 2012 and December 2017 were included and underwent a prospective cognitive and neuropsychiatric assessment every 3 months by cognitive impairment rating scale, Neuropsychiatric Inventory (NPI) and/or Montreal Cognitive Assessment. RESULTS Up to 97.5% patients had severe cognitive deficits and neuropsychiatric symptoms in acute phase. Decreasing proportion of patients with prolonged cognitive deficits was observed and time dependent. At 2 years' follow-up, 7.8% of patients with cognitive deficits were unable to complete some previous activities or return to work. The risk factors associated with persistent cognitive deficits included age of disease onset over 40 years old (HR, 1.77; 95% CI, 1.11-2.82; P = .01) and with clinical relapses (HR, 2.22; 95% CI, 1.21-4.09; P = .02). The predictors of prolonged neuropsychiatric symptoms included clinical relapses (HR, 2.79; 95% CI, 1.21-6.43; P = .02). Among the 12 neuropsychiatric symptoms of NPI, irritability was shown as the most prevalent and persistent. CONCLUSIONS Combined cognitive and neuropsychiatric assessment and intervention are essential elements of comprehensive care of anti-NMDAR encephalitis.
Collapse
Affiliation(s)
- Xu Liu
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Le Zhang
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Chu Chen
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Xue Gong
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Jingfang Lin
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Dongmei An
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Dong Zhou
- Department of Neurology West China Hospital Sichuan University Chengdu China
| | - Zhen Hong
- Department of Neurology West China Hospital Sichuan University Chengdu China
- Department of Pathology University of Washington School of Medicine Seattle WA USA
| |
Collapse
|
50
|
Huang Q, Xie Y, Hu Z, Tang X. Anti-N-methyl-D-aspartate receptor encephalitis: A review of pathogenic mechanisms, treatment, prognosis. Brain Res 2019; 1727:146549. [PMID: 31726044 DOI: 10.1016/j.brainres.2019.146549] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatable autoimmune disorder characterized by prominent neuropsychiatric symptoms that predominantly affects children and young adults. In this review, we discuss the pathogenic mechanisms and immunologic triggers of anti-NMDAR encephalitis, and provide an overview of treatment and prognosis of this disorder, with specific focus on the management of common symptoms, complications, and patients during pregnancy. Most patients respond well to first-line treatment and surgical resection of tumors. When first-line immunotherapy fails, second-line immunotherapy can often improve outcomes. In addition, treatment with immunomodulators and tumor resection are effective treatment strategies for pregnant patients. Benzodiazepines are the preferred treatment for patients with catatonia, and electroconvulsive therapy (ECT) may be considered when pharmacological treatment is ineffective. Age, antibody titer, cerebellar atrophy, levels of biomarkers such as C-X-C motif chemokine 13 (CXCL13), cell-free mitochondrial (mt)DNA in cerebral serum fluid (CSF), and timing from symptom onset to treatment are the main prognostic factors. Patients without tumors or those who receive insufficient immunotherapy during the first episode are more likely to relapse.
Collapse
Affiliation(s)
- Qianyi Huang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yue Xie
- Department of Neurology, The Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Zhiping Hu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
| |
Collapse
|