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Wang H. COVID-19, Anti-NMDA Receptor Encephalitis and MicroRNA. Front Immunol 2022; 13:825103. [PMID: 35392089 PMCID: PMC8980231 DOI: 10.3389/fimmu.2022.825103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/28/2022] [Indexed: 12/16/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on the world, affecting people’s lifestyle, economy, and livelihood. Recently, with the development of vaccines, the number of infected cases has decreased. Many case reports have revealed that COVID-19 may induce other serious comorbidities such as anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis. Anti-NMDA receptor encephalitis is an acute autoimmune disease that occurs more commonly in women than in men. To explore the association between COVID-19 and anti-NMDA receptor encephalitis, the microRNA (miRNA) biomarkers of COVID-19, anti-NMDA receptor encephalitis, and other related diseases from the literature are reviewed; then on the basis of these miRNA biomarkers, the relationship between COVID-19 and anti-NMDA receptor encephalitis is discussed. miRNAs are small non-coding RNAs that play important roles in cell differentiation, development, cell-cycle regulation, and apoptosis. miRNAs have been used as biological biomarkers for many diseases. The results in this study reveal that the relationship between anti-NMDA receptor encephalitis and COVID-19 infection or COVID-19 vaccination cannot be excluded; however, the risk that COVID-19 triggers the anti-NMDA receptor encephalitis is not high.
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Affiliation(s)
- Hsiuying Wang
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
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2
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Anderson D, Nathoo N, Henry M, Wood G, Smyth P, McCombe J. Oophorectomy in NMDA receptor encephalitis and negative pelvic imaging. Pract Neurol 2020:practneurol-2020-002676. [PMID: 33033162 DOI: 10.1136/practneurol-2020-002676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 11/04/2022]
Abstract
Ovarian teratomas are found in one-third of females presenting with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. When a teratoma is detected on imaging, its removal is first-line therapy. Even with multiple imaging modalities, occasionally, the teratoma is found only on subsequent imaging, long after initial presentation. Very rarely, patients have undergone oophorectomy despite negative imaging, with pathology demonstrating teratoma, and resulting clinical improvement. We present a patient in whom removal of a teratoma, not visible on conventional imaging, resulted in marked clinical improvement. Such cases present a major clinical challenge, needing to consider the risks of oophorectomy, including sterilisation and early menopause, versus the possibility of death in the absence of response to first-line (eg, corticosteroids, plasma exchange, intravenous immunoglobulin), second-line (eg, rituximab) and third-line (eg, bortezomib) immunosuppression. This decision is made more difficult as patients are usually females of childbearing age who at the time lack capacity to make medical decisions. This case also highlights the lack of consensus and guidelines for imaging modalities used to detect teratoma and when to pursue oophorectomy.
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Affiliation(s)
| | - Nabeela Nathoo
- Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Monica Henry
- Critical Care, University of Alberta, Edmonton, Canada
| | - George Wood
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Penelope Smyth
- Medicine (Neurology), University of Alberta, Edmonton, Canada
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Abstract
Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.
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Affiliation(s)
- Anne M Meehan
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lena Kassab
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Haixia Qin
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
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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.
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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
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Dai Y, Zhang J, Ren H, Zhou X, Chen J, Cui L, Lang J, Guan H, Sun D. Surgical outcomes in patients with anti-N-methyl D-aspartate receptor encephalitis with ovarian teratoma. Am J Obstet Gynecol 2019; 221:485.e1-485.e10. [PMID: 31128109 DOI: 10.1016/j.ajog.2019.05.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune encephalitis mediated by anti-N-methyl-D-aspartate receptor antibodies. Ovarian teratoma is closely related to anti-N-methyl-D-aspartate receptor encephalitis. However, the optimal treatment remains unknown, and strategies used for the diagnosis and therapy, including surgical intervention of ovarian teratoma, are debatable. OBJECTIVE The objective of the study was to study the clinical features of anti-N-methyl-D-aspartate receptor encephalitis with ovarian teratoma to further understand the disease. STUDY DESIGN This single-center prospective study included patients with anti-NMDAR encephalitis with ovarian teratoma from 2011 to 2016 who were admitted to Peking Union Medical College Hospital, Beijing, and discussed the clinical characteristics, treatment, and prognosis of the disease. The diagnosis of anti-N-methyl-D-aspartate receptor encephalitis was established preoperatively by identifying anti-N-methyl-D-aspartate receptor antibodies in the cerebrospinal fluid. Ovarian teratomas were suspected preoperatively by pelvic ultrasound and were diagnosed pathologically after laparoscopic detection and ovarian tumor resection. All patients were treated with first-line immunotherapy (steroids, intravenous immunoglobulin, and plasmapheresis), and when the therapy failed, they were treated with second-line immunotherapy (cyclophosphamide and rituximab). All patients were followed up regularly, and N-methyl-D-aspartate receptor antibodies, pelvic ultrasound, and neurological condition were monitored. Neurological symptoms were assessed using the modified Rankin Scale. RESULTS A total of 108 female patients with anti-N-methyl-D-aspartate receptor encephalitis were screened, of whom, 29 patients (26.9% of 108; mean age ± SD, 23.14 ± 6.59 years) had pathologically confirmed ovarian teratoma. The incidence of fever, decreased consciousness, arrhythmia, central hypoventilation, ventilator-assisted respiration, and intensive unit care (75.9%, 65.5%, 27.6%, 55.2%, 55.2%, and 58.6%, respectively) were significantly higher in patients with ovarian teratoma than in those without ovarian teratoma. The modified Rankin Scale at the acute onset in those 29 patients was 4.11 ± 1.20, which was also much higher than that in patients without ovarian teratoma (3.58 ± 1.08). Of the 29 patients with ovarian teratoma, 22 (75.9%) underwent laparoscopy during the acute onset of neurological symptoms. The mean diameter of the tumor was 4.61 ± 3.41 cm (SD), and the smallest tumor was only 1 cm in the unilateral ovary. All other cysts, except 4 bilateral cysts (13.8%), were unilateral. Only 1 patient was diagnosed pathologically with immature ovarian teratoma, while others had benign ovarian teratomas. In all, 28 patients (96.5%) had a good outcome (modified Rankin Scale ≤2) and 1 died. In the follow-up visit (mean duration, 37.69 months), the relapse rate of encephalitis in patients with ovarian teratoma undergoing laparoscopic cystectomy was 14.6%, whereas for those without ovarian teratoma, the relapse rate was 33.3%. The removal of ovarian teratoma was associated with reduced risk of relapse. CONCLUSION Patients having anti-N-methyl-D-aspartate receptor encephalitis with ovarian teratomas tend to present more severe neurological conditions. The diameter of the tumor in these patients is not very large and could be as small as 1 cm, and thus, careful exploration should be considered during surgery. Most of the ovarian teratomas in patients with anti-N-methyl-D-aspartate receptor encephalitis are mature. Early operative treatment is safe and effective because it is associated with reduced risk of relapse and complete recovery.
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Affiliation(s)
- Yi Dai
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China
| | - Junji Zhang
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China
| | - Haitao Ren
- Department Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Xingnan Zhou
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China
| | - Juan Chen
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China
| | - Liying Cui
- Department Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Jinghe Lang
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China
| | - Hongzhi Guan
- Department Neurology, Peking Union Medical College Hospital, Beijing, China.
| | - Dawei Sun
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China.
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Phylogenetic Analysis to Explore the Association Between Anti-NMDA Receptor Encephalitis and Tumors Based on microRNA Biomarkers. Biomolecules 2019; 9:biom9100572. [PMID: 31590348 PMCID: PMC6843259 DOI: 10.3390/biom9100572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022] Open
Abstract
MicroRNA (miRNA) is a small non-coding RNA that functions in the epigenetics control of gene expression, which can be used as a useful biomarker for diseases. Anti-NMDA receptor (anti-NMDAR) encephalitis is an acute autoimmune disorder. Some patients have been found to have tumors, specifically teratomas. This disease occurs more often in females than in males. Most of them have a significant recovery after tumor resection, which shows that the tumor may induce anti-NMDAR encephalitis. In this study, I review microRNA (miRNA) biomarkers that are associated with anti-NMDAR encephalitis and related tumors, respectively. To the best of my knowledge, there has not been any research in the literature investigating the relationship between anti-NMDAR encephalitis and tumors through their miRNA biomarkers. I adopt a phylogenetic analysis to plot the phylogenetic trees of their miRNA biomarkers. From the analyzed results, it may be concluded that (i) there is a relationship between these tumors and anti-NMDAR encephalitis, and (ii) this disease occurs more often in females than in males. This sheds light on this issue through miRNA intervention.
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Keskin AO, Tanburoglu A, Idiman E, Ozturk V. Anti‐
N
‐methyl‐
d
‐aspartate receptor encephalitis during pregnancy: A case report. J Obstet Gynaecol Res 2019; 45:935-937. [DOI: 10.1111/jog.13892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/30/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Ahmet O. Keskin
- Department of NeurologyEskisehir Yunus Emre Government Hospital Adana Turkey
| | - Anıl Tanburoglu
- Department of NeurologyBaskent University Faculty of Medicine Adana Turkey
| | - Egemen Idiman
- Department of NeurologyIzmir Dokuz Eylul University Faculty of Medicine Izmir Turkey
| | - Vesile Ozturk
- Department of NeurologyIzmir Dokuz Eylul University Faculty of Medicine Izmir Turkey
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Glutamate Receptor Antibodies in Autoimmune Central Nervous System Disease: Basic Mechanisms, Clinical Features, and Antibody Detection. Methods Mol Biol 2019. [PMID: 30707437 DOI: 10.1007/978-1-4939-9077-1_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Immune-mediated inflammation of the brain has been recognized for more than 50 years, although the initial descriptions were mainly thought to be secondary to an underlying neoplasm. Some of these paraneoplastic encephalitides express serum antibodies, but these were not thought to be pathogenic but instead have a T-cell-mediated pathophysiology. Over the last two decades, several pathogenic antibodies against neuronal surface antigens have been described in autoimmune encephalitis, which are amenable to immunotherapy. Several of these antibodies are directed against glutamate receptors (GluRs). NMDAR encephalitis (NMDARE) is the most common of these antibodies, and patients often present with psychosis, hallucinations, and reduced consciousness. Patients often progress on to develop confusion, seizures, movement disorders, autonomic instability, and respiratory depression. Although initially described as exclusively occurring secondary to ovarian teratoma (and later other tumors), non-paraneoplastic forms are increasingly common, and other triggers like viral infections are now well recognized. AMPAR encephalitis is relatively less common than NMDARE but is more likely to paraneoplastic. AMPAR antibodies typically cause limbic encephalitis, with patients presenting with confusion, disorientation, memory loss, and often seizures. The syndromes associated with the metabotropic receptor antibodies are much rarer and often can be paraneoplastic-mGluR1 (cerebellar degeneration) and mGluR5 (Ophelia syndrome) being the ones described in literature.With the advance in molecular biology techniques, it is now possible to detect these antibodies using cell-based assays with high sensitivity and specificity, especially when coupled with brain tissue immunohistochemistry and binding to live cell-based neurons. The rapid and reliable identification of these antibodies aids in the timely treatment (either in the form of identifying/removing the underlying tumor or instituting immunomodulatory therapy) and has significantly improved clinical outcome in this otherwise devastating group of conditions.
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Suicidality is a common and serious feature of anti-N-methyl-D-aspartate receptor encephalitis. J Neurol 2017; 264:2378-2386. [DOI: 10.1007/s00415-017-8626-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 01/17/2023]
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10
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Abstract
In the last decade, a large number of neuronal cell-surface antibodies have been described which are responsible for a range of neuroimmunological central nervous system disorders. Unlike the paraneoplastic antibodies which target intracellular antigens, these antibodies appear to be pathogenic and hence identification and prompt treatment can make a substantial impact on clinical outcomes of these patients. We review the common antibodies against the ionotropic glutamate receptors (NMDAR, AMPAR), metabotropic glutamate receptors (mGluR1 and mGluR5), voltage-gated potassium channel-complex proteins (LGI1, CASPR2), and other antibodies targeted against glycine receptor, glutamic acid decarboxylase, gamma-amino butyric acid B, dopamine-2-receptor and dipeptidyl-peptidase-like protein 6.
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Affiliation(s)
- A R Karim
- 1 Neuroimmunology, Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | - S Jacob
- 2 Queen Elizabeth Neurosciences Centre, 1732 University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
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Shi YC, Chen XJ, Zhang HM, Wang Z, Du DY. Anti-N-Methyl- d -Aspartate receptor (NMDAR) encephalitis during pregnancy: Clinical analysis of reported cases. Taiwan J Obstet Gynecol 2017; 56:315-319. [DOI: 10.1016/j.tjog.2017.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2016] [Indexed: 11/26/2022] Open
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Zhang L, Wu MQ, Hao ZL, Chiang SMV, Shuang K, Lin MT, Chi XS, Fang JJ, Zhou D, Li JM. Clinical characteristics, treatments, and outcomes of patients with anti-N-methyl-d-aspartate receptor encephalitis: A systematic review of reported cases. Epilepsy Behav 2017; 68:57-65. [PMID: 28109991 DOI: 10.1016/j.yebeh.2016.12.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 11/20/2016] [Accepted: 12/17/2016] [Indexed: 12/24/2022]
Abstract
Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is a recently recognized autoimmune disorder which is responsive to immunotherapy. However, the outcomes of different immunotherapies have not been defined and there have been few studies that carried out a comparison among them. To provide an overview of the clinical characteristics, treatments, and outcomes of anti-NMDAR encephalitis, we systematically reviewed the literature in the PubMed, Medline, Embase, Cochrane Library, BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wan-fang databases. Eighty-three studies with a total of 432 patients were included. The median age was 22years. Two hundred ninety-three (68%) patients were female, 87 (21%) of 412 patients had a tumor, including 68 (78%) patients with ovarian teratoma. Pediatric patients had a higher ratio of seizures to psychiatric symptoms as the initial manifestation (p=0.0012), a lower proportion with a tumor (p<0.0001) and CSF pleocytosis (p=0.0163), and a better outcome (p=0.0064) than adults. Patients who died had a higher proportion of CSF pleocytosis than the patients who survived (p=0.0021). There were no significant differences among three first-line immunotherapy used alone (p=0.9172) or among combinations of every two of them (p=0.3059). With regard to the use of corticosteroid and IVIG, there were no significant differences between the outcomes of early combined treatment and sequential treatment (p=0.7277), or between using corticosteroid first and IVIG first (p=0.5422). Our findings suggest that the clinical characteristics and outcomes for pediatric patients were different from adult patients, and no significant differences were found among different immunotherapies.
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Affiliation(s)
- Le Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Meng-Qian Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zi-Long Hao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Siew Mun Vance Chiang
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Kun Shuang
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Min-Tao Lin
- West China College of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao-Sa Chi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Jia Fang
- Department of Neurology, Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, Zhejiang Province, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Abdul-Rahman ZM, Panegyres PK, Roeck M, Hawkins D, Bharath J, Grolman P, Neppe C, Palmer D. Anti-N-methyl-D-aspartate receptor encephalitis with an imaging-invisible ovarian teratoma: a case report. J Med Case Rep 2016; 10:296. [PMID: 27776544 PMCID: PMC5078958 DOI: 10.1186/s13256-016-1067-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis is a recently discovered disease entity of paraneoplastic limbic encephalitis. It largely affects young women and is often associated with an ovarian teratoma. It is a serious yet treatable condition if diagnosed early. Its remedy involves immunotherapy and surgical removal of the teratoma of the ovaries. This case of anti-N-methyl-D-aspartate receptor encephalitis involves an early surgical intervention with bilateral oophorectomy, despite negative imaging evidence of a teratoma. CASE PRESENTATION A 25-year-old white woman with anti-N-methyl-D-aspartate receptor encephalitis presented with behavioral changes and seizures that were confirmed to be secondary to anti-N-methyl-D-aspartate receptor encephalitis. She required an admission to our intensive care unit for ventilator support and received a number of immunological therapies. Multiple imaging investigations showed no evidence of an ovarian teratoma; she had a bilateral oophorectomy 29 days after admission. Ovarian histology confirmed the presence of a teratoma with neuronal cells. A few days after the operation she began to show signs of improvement and, apart from mild short-term memory loss, she returned to normal function. CONCLUSIONS Our patient is an example of teratoma-associated anti-N-methyl-D-aspartate receptor encephalitis, in which the teratoma was identified only microscopically. Her case highlights that even with negative imaging evidence of a teratoma, ovarian pathology should still be considered and explored.
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Affiliation(s)
- Zainab M Abdul-Rahman
- Department of Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia.,Academy of Neurology, Joondalup Health Campus, Joondalup, Western Australia, Australia.,Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth, Western Australia, 6005, Australia
| | - Peter K Panegyres
- Department of Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia. .,Academy of Neurology, Joondalup Health Campus, Joondalup, Western Australia, Australia. .,Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth, Western Australia, 6005, Australia. .,Department of Medicine, The University of Western Australia, Perth, Western Australia, Australia.
| | - Margareta Roeck
- Ramsay Health, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - David Hawkins
- Ramsay Health, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jude Bharath
- Ramsay Health, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Paul Grolman
- Ramsay Health, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Cliffe Neppe
- Ramsay Health, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - David Palmer
- Western Diagnostic Pathology, Joondalup Health Campus, Joondalup, Western Australia, Australia
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Scheer S, John RM. Anti-N-Methyl-D-Aspartate Receptor Encephalitis in Children and Adolescents. J Pediatr Health Care 2016; 30:347-58. [PMID: 26507948 DOI: 10.1016/j.pedhc.2015.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 12/18/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease that is becoming increasingly recognized in the pediatric population. It may be the most common cause of treatable autoimmune encephalitis. The majority of cases of anti-NMDAR encephalitis are idiopathic in etiology, but a significant minority can be attributed to a paraneoplastic origin. Children with anti-NMDAR encephalitis initially present with a prodrome of neuropsychiatric symptoms, often with orofacial dyskinesias followed by progressively worsening seizures, agitation, and spasticity, which may result in severe neurologic deficits and even death. Definitive diagnosis requires detection of NMDAR antibodies in the cerebrospinal fluid. Optimal outcomes are associated with prompt removal of the tumor in paraneoplastic cases, as well as aggressive immunosuppressive therapy. Early detection is essential for increasing the chances for a good outcome. Close follow-up is required to screen for relapse and later onset tumor presentation. The nurse practitioner plays a major role in the research, screening, diagnosis, treatment, follow-up, and rehabilitation of a child or adolescent with anti-NMDAR encephalitis.
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Fischer CE, Golas AC, Schweizer TA, Munoz DG, Ismail Z, Qian W, Tang-Wai DF, Rotstein DL, Day GS. Anti N-methyl-D-aspartate receptor encephalitis: a game-changer? Expert Rev Neurother 2016; 16:849-59. [PMID: 27123777 DOI: 10.1080/14737175.2016.1184088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an inflammatory disorder of the brain that has garnered significant interest within the medical and lay communities. There is a need for formal guidelines to assist physicians in identifying patients who should undergo testing for NMDAR encephalitis, recognizing the high potential for this potentially treatable disease to mimic more common disorders, and consequently remain undiagnosed. AREAS COVERED This review highlights the impact of the discovery of NMDAR encephalitis on the fields of neurology and psychiatry, and discusses the steps that are necessary to improve recognition and treatment of NMDAR encephalitis. Expert commentary: While much progress has been made in our understanding of NMDAR encephalitis, much work remains to be done to delineate the underlying disease mechanisms and their relevance to brain function.
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Affiliation(s)
- Corinne E Fischer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,c Faculty of Medicine, Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Angela C Golas
- d Department of Psychiatry , University of Toronto, Geriatric Psychiatry Subspecialty , Toronto , ON , Canada
| | - Tom A Schweizer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,e Institute of Biomaterials and Biomedical Engineering , University of Toronto , Toronto , ON , Canada.,f Division of Neurosurgery, Department of Surgery, Faculty of Medicine , University of Toronto , Toronto , ON , Canada.,g Division of Neurosurgery , St. Michael's Hospital , Toronto , ON , Canada
| | - David G Munoz
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,h Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , ON , Canada.,i Division of Pathology, Department of Laboratory Medicine and Pathobiology , St. Michael's Hospital , Toronto , ON , Canada
| | - Zahinoor Ismail
- j Hotchkiss Brain Institute , University of Calgary , Calgary , AB , Canada
| | - Winnie Qian
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada
| | - David F Tang-Wai
- k Department of Medicine (Neurology and Geriatric Medicine) , University of Toronto , Toronto , ON , Canada.,l UHN Memory Clinic , Toronto Western Hospital , Toronto , ON , Canada
| | - Dalia L Rotstein
- m Department of Medicine (Neurology) , University of Toronto, St. Michael's Hospital , Toronto , ON , Canada
| | - Gregory S Day
- n Knight Alzheimer Disease Research Center, Department of Neurology , Washington University in St. Louis , St. Louis , MO , Canada
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Vargas RJ, Farid H, Goldenson RP, Fairchild AH, Dorton BJ, Bromley BS. Ovarian Teratomas and Anti-N-Methyl-d-Aspartate Receptor Encephalitis: Why Sonography First? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:852-854. [PMID: 27022186 DOI: 10.7863/ultra.15.04064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Roberto J Vargas
- Department of Obstetrics and GynecologyBrigham and Women's Hospital andMassachusetts General HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
| | - Huma Farid
- Department of Obstetrics and GynecologyBrigham and Women's Hospital andMassachusetts General HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
| | - Robin P Goldenson
- Department of RadiologyBrigham and Women's HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
| | - Alexandra H Fairchild
- Department of RadiologyBrigham and Women's HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
| | - Benjamin J Dorton
- Department of Obstetrics and GynecologyBrigham and Women's Hospital andMassachusetts General HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
| | - Bryann S Bromley
- Department of Obstetrics and GynecologyBrigham and Women's Hospital andMassachusetts General HospitalBoston, Massachusetts USADepartment of RadiologyBrigham and Women's HospitalBoston, Massachusetts USAHarvard Medical SchoolBoston, Massachusetts USA
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Yu X, Qin D, Ma D, Yao Q. Adult dermatomyositis associated with benign ovarian teratoma: A case report. Oncol Lett 2016; 11:2611-2614. [PMID: 27073526 DOI: 10.3892/ol.2016.4251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 01/28/2016] [Indexed: 01/01/2023] Open
Abstract
A 27-year-old female patient presented with a 3-month history of bilateral orbital and facial edema accompanied by skin erythema and heliotrope rash. The left lesion was more critical than the right. Limb muscles were occasionally sore. On physical examination, scattered hemorrhagic rashes were observed on the patient's face and neck. Upon laboratory testing, creatine kinase (CK) was markedly elevated at 1,543.2 U/l, while CK-MB isoenzyme (27.4 U/l), α-hydroxybutyric dehydrogenase (188.4 U/l) and aspartate aminotransferase (65.3 U/l) were marginally elevated. The patient was diagnosed with dermatomyositis due to the dermatological features and elevated CK. Cancer marker analysis revealed positivity for carbohydrate antigen 125 (68.15 U/ml). Magnetic resonance imaging revealed thickening of the soft tissue of the left eyelid; furthermore, concurrent long T1- and T2-weighted signals (fat saturation) were compatible with inflammatory infiltration. Non-enhanced computed tomography identified that the right accessory region (right ovary and fallopian tube) had a cystic mass with a significant fat component and thickening of the anterior uterine wall. Gynecological ultrasound findings indicated an ovarian teratoma (8.7×7.8×9.3 cm) and uterine myoma (3.6×3.1 cm). The patient's dermatological symptoms and laboratory results were significantly relieved one week after surgical removal of the teratoma with the aid of hydrocortisone, methylprednisolone and methotrexate therapy.
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Affiliation(s)
- Xiaomin Yu
- Department of Obstetrics and Gynaecology, Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China; Department of Obstetrics and Gynaecology, The Eighth People's Hospital of Qingdao, Qingdao, Shandong 266100, P.R. China
| | - Dongyan Qin
- Department of Obstetrics and Gynaecology, Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Dehua Ma
- Department of Obstetrics and Gynaecology, Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Qin Yao
- Department of Obstetrics and Gynaecology, Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
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Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an acute autoimmune neurological disorder that presents with acute to subacute psychiatric and/or neurological complaints including new onset behavioral changes that may evolve to psychosis and catatonia, cognitive decline, new onset seizures, progressive encephalopathy, and/or movement disorders. Female teens and adults often have an associated ovarian teratoma as an underlying etiology, but most pediatric patients do not have an identifiable associated neoplasm. The diagnosis requires confirmatory serum and/or cerebrospinal fluid analysis findings of anti-NMDAR antibody titers. It can be misdiagnosed as a psychiatric condition or a viral encephalitis. The clinical features that distinguish anti-NMDAR encephalitis from a primary psychiatric disorder are the acute onset of the mood and behavioral changes with no history, the waxing and waning of consciousness (delirium/encephalopathy), and primary neurological features such as seizures and abnormal involuntary movements, including dyskinesias and dystonias. The prognosis is improved with earlier recognition and prompt immunotherapy treatment, making this an important diagnosis for emergency physicians.
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Kim SW, Lee HS, Lee PH, Choi SA. Anti-NMDA Receptor Encephalitis with a Favorable Prognosis Despite Delayed Treatment Due to Longstanding Psychiatric Symptoms. Mov Disord Clin Pract 2014; 1:386-387. [DOI: 10.1002/mdc3.12095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/25/2014] [Accepted: 09/07/2014] [Indexed: 11/08/2022] Open
Affiliation(s)
- Seung Woo Kim
- Department of Neurology; Yonsei University College of Medicine; Seoul Korea
| | - Hyung Seok Lee
- Department of Neurology; Yonsei University College of Medicine; Seoul Korea
| | - Phil Hyu Lee
- Department of Neurology; Yonsei University College of Medicine; Seoul Korea
| | - Sun-Ah Choi
- Department of Neurology; National Health Insurance Service; Ilsan Hospital; Koyang Korea
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Acién P, Acién M, Ruiz-Maciá E, Martín-Estefanía C. Ovarian teratoma-associated anti-NMDAR encephalitis: a systematic review of reported cases. Orphanet J Rare Dis 2014; 9:157. [PMID: 25312434 PMCID: PMC4203903 DOI: 10.1186/s13023-014-0157-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/01/2014] [Indexed: 12/24/2022] Open
Abstract
The association of ovarian teratoma and anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a serious and potentially fatal pathology that occurs in young women and that is under-recognized. Our objectives were to analyze prevalence and outcome of this association, and increase awareness over this pathology. MEDLINE and SCOPUS for all studies published prior to November 30, 2013 including the search terms: "encephalitis" and "teratoma" were considered. All articles (119) reporting one or more cases of anti-NMDAR encephalitis and confirmed ovarian teratoma (174 cases) were included. No language restrictions were applied. Suspicious cases with no evidence of ovarian teratoma (n = 40) and another type of encephalitis also associated to ovarian teratoma (n = 20) were also considered for comparison and discussion. Data of publication and case report, surgery and outcome were collected. The distribution of published cases is heterogeneous among different countries and continents, probably in relation with level of development and health care. The mean patient age is 24 years and in the majority of cases (74%), a mature teratoma was identified, sometimes microscopically following ovarian removal or at autopsy. The clinical presentation featured psychiatric symptoms and behavioural changes, with a median delay for surgery of 28 days. Twelve women died (7%), most frequently from encephalitis-related complications. In conclusion, the association ovarian teratoma and anti-NMDAR encephalitis is relatively unknown or not reported in many countries and among gynecologists. Heightened recognition of behavioral changes, diagnosis through transvaginal ultrasound and subsequent tumor removal in addition to diagnostic confirmation through the presence of anti-NMDAR antibodies must be emphasized.
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Affiliation(s)
- Pedro Acién
- />Obstetrics and Gynecology Service, San Juan University Hospital, Alicante, Spain
- />Department/Division of Gynecology, Miguel Hernández University, San Juan Campus, 03550 Alicante, Spain
| | - Maribel Acién
- />Obstetrics and Gynecology Service, San Juan University Hospital, Alicante, Spain
- />Department/Division of Gynecology, Miguel Hernández University, San Juan Campus, 03550 Alicante, Spain
| | - Eva Ruiz-Maciá
- />Obstetrics and Gynecology Service, San Juan University Hospital, Alicante, Spain
- />Department/Division of Gynecology, Miguel Hernández University, San Juan Campus, 03550 Alicante, Spain
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Paraneoplastic neurological syndromes associated with ovarian tumors. J Cancer Res Clin Oncol 2014; 141:99-108. [PMID: 24965744 PMCID: PMC4282879 DOI: 10.1007/s00432-014-1745-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/10/2014] [Indexed: 01/10/2023]
Abstract
Introduction Paraneoplastic neurological syndromes (PNS) are neurologic deficits triggered by an underlying remote tumor. PNS can antedate clinical manifestation of ovarian malignancy and enable its diagnosis at an early stage. Interestingly, neoplasms associated with PNS are less advanced and metastasize less commonly than those without PNS. This suggests that PNS may be associated with a naturally occurring antitumor response. Methods We review the literature on the diagnosis, pathogenesis and management of PNS associated with ovarian tumors: paraneoplastic cerebellar degeneration (PCD) and anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. An approach to the diagnostic workup of underlying tumors is discussed. Results PCD can precede the manifestation of ovarian carcinoma. Anti-NMDAR encephalitis in young women appears often as a result of ovarian teratoma. Since ovarian tumors and nervous tissue share common antigens (e.g., cdr2, NMDAR), autoimmune etiology is a probable mechanism of these neurologic disorders. The concept of cross-presentation, however, seems insufficient to explain entirely the emergence of PNS. Early resection of ovarian tumors is a significant part of PNS management and improves the outcome. Conclusions The diagnosis of PNS potentially associated with ovarian tumor indicates a need for a thorough diagnostic procedure in search of the neoplasm. In some patients, explorative laparoscopy/laparotomy can be considered.
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Anti-N-methyl-aspartate receptor encephalitis in identical twin sisters: role for oophorectomy. Obstet Gynecol 2014; 123:433-435. [PMID: 24413237 DOI: 10.1097/aog.0000000000000078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-N-methyl-aspartate receptor encephalitis is a potentially fatal form of encephalitis and frequently associated with ovarian teratomas. Surgical removal of ovarian teratomas improves clinical outcome, but it is unclear whether bilateral salpingo-oophorectomy for normal-appearing ovaries is of clinical benefit. CASE Our report describes a unique clinical scenario of identical twin sisters with anti-N-methyl-aspartate receptor encephalitis. Neither patient responded to immunosuppressive therapy. Imaging studies showed normal-appearing ovaries. The first twin continued on medical therapy only and died of the disease. The second twin underwent a bilateral salpingo-oophorectomy followed by gradual recovery. CONCLUSION Based on our experience in two genetically identical individuals, we suggest considering the removal of normal-appearing ovaries in patients with anti-N-methyl-aspartate receptor encephalitis who fail to respond to medical treatment.
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Marcos-Arribas L, Almonacid JJ, Dolado AM. Neuropsychological Profile of Anti-NMDA Receptor Encephalitis. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/psych.2013.410110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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