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Bandeira GG, Barreto Lima PLGDS, Araújo DABS, Pinheiro MSN, Albuquerque Mota LD, Simão RM, de Carvalho FMO, Vazquez FD, de Vasconcelos Gama VC, de Queiroz DC, da Fonseca Lira MZR, de Oliveira Júnior PH, Guimarães Junior FA, Caminha GC, de Figueiredo Santos C, Sobreira-Neto MA, Braga-Neto P, Silva GD, Nóbrega PR. Controversies in immunotherapy for anti-NMDA receptor encephalitis: a scoping review with a proposal of operational definitions. Neurol Sci 2023; 44:4307-4312. [PMID: 37597088 DOI: 10.1007/s10072-023-07018-x] [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: 06/13/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Anti-NMDA receptor encephalitis (NMDARE), an autoimmune encephalitis associated with autoantibodies against the N-methyl-D-aspartate (NMDA) receptor, affects predominantly young women and is associated with psychiatric symptoms, seizures, movement disorders, and autonomic instability. Traditional treatments of anti-NMDA receptor encephalitis involve corticosteroids, intravenous immunoglobulin, plasmapheresis, cyclophosphamide, and rituximab. However, many controversies remain in the treatment for NMDA receptor encephalitis, such as optimal timing and combination of different immunotherapies, the role of newer strategies (e.g., bortezomib or tocilizumab) for severe and refractory patients, and the need or not for long-term immunosuppression. Our goal was to perform a scoping review to discuss the controversial topics of immunotherapy for NMDA receptor encephalitis and propose operational definitions to guide clinical practice and future research in the field.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carolina de Figueiredo Santos
- Universidade de Fortaleza, Ceara, Fortaleza, Brazil
- Hospital Infantil Albert Sabin, Ceara, Fortaleza, Brazil
- Núcleo de Tratamento e Estimulação Precoce, Federal University of Ceara, Fortaleza, Brazil
| | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Fortaleza, Brazil
| | - Guilherme Diogo Silva
- Division of Neurology, Hospital of Clinics, University of São Paulo, São Paulo, Brazil
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The Role of Glutamate Receptors in Epilepsy. Biomedicines 2023; 11:biomedicines11030783. [PMID: 36979762 PMCID: PMC10045847 DOI: 10.3390/biomedicines11030783] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Glutamate is an essential excitatory neurotransmitter in the central nervous system, playing an indispensable role in neuronal development and memory formation. The dysregulation of glutamate receptors and the glutamatergic system is involved in numerous neurological and psychiatric disorders, especially epilepsy. There are two main classes of glutamate receptor, namely ionotropic and metabotropic (mGluRs) receptors. The former stimulate fast excitatory neurotransmission, are N-methyl-d-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainate; while the latter are G-protein-coupled receptors that mediate glutamatergic activity via intracellular messenger systems. Glutamate, glutamate receptors, and regulation of astrocytes are significantly involved in the pathogenesis of acute seizure and chronic epilepsy. Some glutamate receptor antagonists have been shown to be effective for the treatment of epilepsy, and research and clinical trials are ongoing.
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Iyengar Y, Hébert J, Climans SA, Muccilli A, Lee S, Boruah AP, Thakur KT, Solnik J, Wennberg RA, Day GS, Tang-Wai DF. Ovarian resection in anti-N-methyl-D-aspartate receptor encephalitis: A comparison of surgical approaches. Front Neurol 2022; 13:1043785. [DOI: 10.3389/fneur.2022.1043785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
BackgroundFor patients with anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) and ovarian teratoma, “conservative” surgical approaches (complete or partial unilateral oophorectomy or bilateral partial oophorectomies) are associated with clinical improvement. “Aggressive” ovarian resections (complete bilateral oophorectomy or “blind” ovarian resections without pre-operative evidence of teratoma) are also reported, although the evidence supporting these approaches is unclear.ObjectiveTo compare the one-year functional outcomes of patients with NMDARE who underwent conservative vs. aggressive ovarian resections.MethodsPatients with NMDARE undergoing ovarian resection between January 1st, 2012 and December 31st, 2021 were retrospectively identified from three North American tertiary care centers. Primary outcome was a modified Rankin Scale score of 0–2 one year after ovarian resection. Fisher exact and Wilcoxon rank sum tests were used to compare demographic features, disease characteristics, and functional outcomes between the two surgical groups. A fixed-effects meta-analysis of studies reporting functional outcomes based on surgical approach was also performed.ResultsTwenty-three patients were included. Eight underwent aggressive surgical management. There was a non-significant trend toward an association between aggressive surgical management and younger age-at-onset, higher baseline disease severity, and longer delays to treatment. There was no difference between “aggressive” (3/8, 38%) and “conservative” (11/15, 73%) management groups in achieving the primary outcome (OR95% = <0.1–1.9; p = 0.18). Findings were similar when considering data from 52 patients in two published studies (RR = 0.74; CI95% = 0.48–1.13; p = 0.16).ConclusionsAggressive ovarian resection was not associated with improved outcomes in patients with NMDARE in this series. Group differences may have contributed, recognizing that patients who underwent aggressive resection tended to be sicker, with procedures performed later in the disease course. Based on available evidence, we advocate for function-sparing resection in patients with imaging-confirmed/suspected teratoma, and repeated multi-modal imaging in at-risk patients with NMDARE refractory to conventional treatment.
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Duong SL, Prüss H. Paraneoplastic Autoimmune Neurological Syndromes and the Role of Immune Checkpoint Inhibitors. Neurotherapeutics 2022; 19:848-863. [PMID: 35043373 PMCID: PMC9294109 DOI: 10.1007/s13311-022-01184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
The introduction of immune checkpoint inhibitors (ICIs) in oncologic therapies has led to a paradigm shift in cancer treatment. ICIs have increased the overall survival in patients with malignant melanoma, small-cell lung cancer, and many other tumor entities. Despite their clinical benefits, these novel cancer immunotherapies can induce neurological immune-related adverse events (irAEs). Such immune-mediated complications can manifest within the spectrum of paraneoplastic neurological syndromes (PNSs). PNSs are rare immune-mediated complications of systemic cancers that can involve every aspect of the nervous system. The emergence of PNSs with ICI treatment opens further pathways to study the complex immunopathological interplay of cancer immunity, cross-reactive neurological autoimmune phenomena, and effects of ICIs on the immune system. ICI-induced PNSs comprise a diverse antibody repertoire and phenotypic spectrum with severe and life-threatening disease progression in some cases. Timely diagnosis and urgent interventions are pivotal for a favorable neurologic and oncologic outcome. This review focuses on the pathogenesis of cancer immunotherapy and the disruption of immune tolerance in PNSs and provides an overview of the most pertinent clinical manifestations and principles of diagnostic and therapeutic managements in light of the expected increase in PNSs due to the widespread use of ICIs in clinical practice. This review further discusses potential and evolving concepts of therapeutic monoclonal antibodies for the treatment of PNSs.
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Affiliation(s)
- Sophie L Duong
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany.
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Chetram DK, Pan K, Elfasi A, Markham M. Anti-NMDAR encephalitis presenting after immature teratoma resection. BMJ Case Rep 2021; 14:e244637. [PMID: 34799390 PMCID: PMC8606781 DOI: 10.1136/bcr-2021-244637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 12/22/2022] Open
Abstract
This is a case of a young woman who developed neurological and psychiatric symptoms 3 days after resection of an immature teratoma. She was diagnosed with anti-NMDA receptor encephalitis via positive serum antibody titres, which was later confirmed with cerebrospinal fluid antibody titres. Given her cancer diagnosis, she underwent treatment with bleomycin, etoposide and cisplatin chemotherapy in addition to 5 days of high-dose steroids (1 g of intravenous methylprednisolone) for the encephalitis. This treatment regimen led to significant clinical improvement 3 weeks after completion of one cycle of chemotherapy.
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Affiliation(s)
| | - Kelsey Pan
- Internal Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Aisha Elfasi
- Neurology, University of Florida Health, Gainesville, Florida, USA
| | - Merry Markham
- Medicine, Division of Hematology & Oncology, University of Florida, Gainesville, Florida, USA
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6
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Koenig ZA, Yednock JB, Akers JL. Anti-N-methyl-D-aspartate Receptor Encephalitis as a Paraneoplastic Presentation of Mature Ovarian Teratoma. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933240. [PMID: 34665797 PMCID: PMC8544169 DOI: 10.12659/ajcr.933240] [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] [Indexed: 11/17/2022]
Abstract
Patient: Female, 26-year-old
Final Diagnosis: Anti NMDA receptor encephalitis • familial adenomatous polyposis
Symptoms: Autonomic instability • catatonia • ovarian cyst • psychosis
Medication: —
Clinical Procedure: Ovariectomy
Specialty: General and Internal Medicine
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Affiliation(s)
- Zachary A Koenig
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Joel B Yednock
- West Virginia University School of Medicine, Morgantown, WV, USA
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Gu J, Chen Q, Gu H, Duan R. Research progress in teratoma-associated anti-N-methyl-D-aspartate receptor encephalitis: The gynecological perspective. J Obstet Gynaecol Res 2021; 47:3749-3757. [PMID: 34396640 DOI: 10.1111/jog.14984] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 12/20/2022]
Abstract
AIM Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the autoimmune encephalitis, which often occurs in children and young adults, especially in young women. In addition to viral infection, teratoma is an important causative factor. Anti-NMDAR encephalitis is well known to neurologist. However, this is less well known to gynecologists, who may have a decisive role in etiological management. Therefore, from the perspective of gynecologists, we provide an overview of the relationship between the encephalitis and ovarian teratoma, the clinical features and treatment of this disease, and prognosis of pregnant women with this encephalitis. METHODS We searched the PubMed database using the search terms in various combinations "teratoma," "dermoid cyst," "ovary," "ovarian," "anti-NMDAR encephalitis," and "N-methyl-D-aspartate receptor." RESULTS According to the current literature, the mechanism of anti-NMDAR encephalitis is probably due to the ectopic expression of the NMDAR in the teratomas tissue. The disease has a high mortality rate if not treated promptly and effectively. An important way to improve patients' outcome is to remove the ovarian tumor in time. Pregnant women are also at risk of developing anti-NMDAR encephalitis during pregnancy. The fetal outcome is usually better in patients with mid- to late-pregnancy onset than in early pregnancy, and patients are often able to maintain their pregnancies into late pregnancy. CONCLUSION Young women with sudden onset of abnormal psychiatric behavior should be actively screened for ovarian tumors and, if confirmed to be teratoma-associated anti-NMDAR encephalitis, should undergo gynecologic surgery as early as possible, which can help improve their prognosis.
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Affiliation(s)
- Jiaxin Gu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, China
| | - Qian Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, China
| | - Handong Gu
- Department of Radiology, DaZhou Central Hospital, Dazhou, China
| | - Ruiqi Duan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, China
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He X, Zhao X, Wang X, Liang G, Qi H, Zhu C, Huang Z, Zhang J. Distinctive pattern of left-right asymmetry of ovarian benign teratomas in Chinese population: a 12-year-long cross-sectional study. Arch Gynecol Obstet 2021; 303:729-737. [PMID: 33427916 PMCID: PMC7960580 DOI: 10.1007/s00404-020-05864-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022]
Abstract
Purpose Given the lack of research on the left–right asymmetry of ovarian teratoma among Chinese patients, this study aimed to determine the lateral distribution and related clinical characteristics of Chinese ovarian teratoma patients treated at a single center. Methods We conducted a cross-sectional study of surgical patients pathologically diagnosed with ovarian teratomas in the gynecology inpatient department of the International Peace Maternity and Child Health Hospital in Shanghai between July 2006 and July 2018. Results Of the 4417 patients with ovarian teratoma, 3835 were finally analyzed. There were 2030 (53.24%) cases of right-sided benign ovarian teratoma versus 1783 (46.76%) cases of left-sided benign teratoma (P < 0.001). The recurrence rate of benign ovarian teratoma was 4.2%; recurrence occurred more often on the left side (left vs. right = 55 vs. 45%, P = 0.033). Compared with the right-sided ovarian teratoma patients, left-sided ones had significantly high recurrence risk (OR 1.430; 95% CI 1.03–1.99). The rate of ovarian torsion in patients with ovarian mature cystic teratomas (MCTs) during intrauterine pregnancy was 3.17 versus 1.72% in non-pregnant MCT patients (P = 0.049). For those MCT patients with intrauterine pregnancy, ovarian torsion occurs more often on the right side (left vs. right = 16.67 vs. 83.33%, P = 0.028). Conclusion This study confirms a distinctive right-side dominance of benign ovarian teratomas. Compared with the right side, recurrent ovarian teratomas occur more often on the left side, requiring close follow-up. Intrauterine pregnancy may increase the risk of ovarian torsion, particularly on the right side, in MCT patients.
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Affiliation(s)
- Xiaoqing He
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Xiaoya Zhao
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Xiaofeng Wang
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Guiling Liang
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Hang Qi
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Chenfeng Zhu
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Zhen Huang
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jian Zhang
- Department of Obstetrics and Gynecology, School of Medicine, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China. .,Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China. .,Shanghai Municipal Key Clinical Specialty, Shanghai, China.
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Hong SB, Shin YW, Moon J, Lee WJ, Chu K, Lee SK. Initial cerebrospinal fluid-restricted oligoclonal bands associate with anti-N-methyl-D-aspartate receptor encephalitis severity: a pilot study. ENCEPHALITIS 2021; 1:7-13. [PMID: 37492497 PMCID: PMC10295873 DOI: 10.47936/encephalitis.2020.00038] [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: 11/02/2020] [Accepted: 10/09/2020] [Indexed: 07/27/2023] Open
Abstract
Purpose Intrathecal antibody production is thought to underly the pathogenesis and symptomatology of N-methyl-D-aspartate receptor encephalitis (NMDARE). In the present study, the clinical correlation of cerebrospinal fluid (CSF) restricted oligoclonal bands (OCBs), as a measure of intrathecal antibody synthesis, was examined in confirmed NMDARE cases. Methods The present study included patients with a confirmed diagnosis of NMDARE who underwent initial CSF evaluation and were followed up for a minimum of 12 months. Disease severity was assessed at baseline and 1, 3, 6, 9, and 12 months. Data regarding duration of hospitalization and intensive care unit (ICU) stay, the presence of uncontrolled seizures, and antiepileptic drug requirement were obtained for each patient. Results Among the 14 confirmed NMDARE patients, seven had CSF-OCBs. The presence of CSF-OCBs was associated with a more severe disease at baseline (p = 0.004), worse final outcome (p = 0.005), and longer hospitalization (median, 19 vs. 173 days; p < 0.001) and ICU stay (median, 0 vs. 29 days; p = 0.006). CSF-OCB positivity was closely associated with treatment refractoriness within 4 weeks (p = 0.029). Conclusion The presence of CSF-OCBs at the onset of disease in NMDARE patients was associated with initial treatment refractoriness and a more severe disease course leading to longer hospitalization, ICU admission, intractable seizures, and a poorer outcome. The results indicate that CSF-OCBs may be useful for prognostication. Furthermore, severe disease in NMDARE may be accompanied by oligoclonal expansion antibody-producing B cells.
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Affiliation(s)
- Sang Bin Hong
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yong-Won Shin
- Department of Neurosurgery, Center for Hospital Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jangsup Moon
- Rare Disease Center, Seoul National University Hospital, Seoul, Korea
| | - Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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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.
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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.
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Abstract
Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.
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Serra-Mestres J, Villagrasa-Blasco B, Thacker V, Jaimes-Albornoz W, Sharma P, Isetta M. Catatonia in N-methyl-d-aspartate receptor antibody encephalitis: Phenomenological characteristics from a systematic review of case reports. Gen Hosp Psychiatry 2020; 64:9-16. [PMID: 32070914 DOI: 10.1016/j.genhosppsych.2020.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To ascertain the phenomenological characterisation of catatonia in N-methyl-d-aspartate receptor antibody encephalitis (NMDAr-AbE). METHODS A systematic review of case reports was undertaken in accordance with PRISMA guidelines. Case reports of NMDAr-AbE containing sufficient information on the cases' clinical presentation and meeting the study's inclusion criteria were selected. Cases were searched for clinical data in keeping with core catatonic signs by applying the screening instrument of the Bush-Francis Catatonia Rating Scale. When two or more core signs were ascertained catatonia was considered to be present. RESULTS 2645 records were identified through the database search. Following screening and application of eligibility/inclusion criteria 139 articles were selected reporting on 189 individual subjects. Catatonia was present in 60% of these cases. The most prevalent signs were immobility/stupor (70%), mutism (67%), excitement (50%), posturing/catalepsy (34%), stereotypies (31%), and rigidity (30%). Immobility/stupor and excitement co-occurred in the same patient in 33% of cases. CONCLUSION The phenomenological profile of catatonia in this sample of cases of NMDAr-AbE was characterised by a preponderance of signs in the hypokinetic spectrum. However, excitement often co-occurred in these patients suggesting that fluctuations in catatonic semiology may be frequent.
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Affiliation(s)
- Jordi Serra-Mestres
- Department of Old Age Psychiatry, Central & North West London NHS Foundation Trust, Woodland Centre, Hillingdon Hospital, Uxbridge UB8 3NN, UK.
| | - Beatriz Villagrasa-Blasco
- Àrea de Psicogeriatria, Benito Menni CASM, C/Dr. Pujades 38, 08830 Sant Boi de Llobregat, Catalunya, Spain
| | - Vikram Thacker
- Trust, Abraham Cowley Unit, Holloway Hill, Lyne, Chertsey, Surrey, KT16 0AE, UK
| | - Walter Jaimes-Albornoz
- Psychiatry Service, Hospital Universitario Donostia, Begiristain Doktorea Pasealekua 109, 20014 Donostia-San Sebastian, Basque Country, Spain
| | - Puja Sharma
- Department of Old Age Psychiatry, Central & North West London NHS Foundation Trust, Woodland Centre, Hillingdon Hospital, Uxbridge UB8 3NN, UK
| | - Marco Isetta
- Library and Knowledge Services, Central & North West London NHS Foundation Trust, St Charles' Hospital, 125 Exmoor Street, London W10 6DZ, UK
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John CM, Mathew DE, Abdelaziz M, Mahmoud AAH, AlOtaibi AD, Sohal APS. Anti- N-methyl-d-aspartate Receptor Encephalitis: A Case Series and Review of the Literature. J Pediatr Neurosci 2019; 14:180-185. [PMID: 31908658 PMCID: PMC6935983 DOI: 10.4103/jpn.jpn_83_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022] Open
Abstract
Anti-NMDAR (N-methyl-d-aspartate receptor) encephalitis is a potentially severe form of encephalitis associated with antibodies against NR1 and NR2 subunits of the NMDAR. Anti-NMDAR encephalitis is a treatable cause of encephalitis. An underlying tumor should be actively looked for as this is also considered to be a paraneoplastic syndrome. We report two children with anti-NMDAR encephalitis with a literature review of current evidence in diagnosing and managing this rare condition. Resection of the tumor, glucocorticoids, intravenous immunoglobulin, and plasma exchange often result in improvement, usually within four weeks. Outcome corresponds with the rapidity of commencing appropriate treatment.
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Affiliation(s)
- Cheri M John
- Angels Speciality Clinic, Chennai, Tamil Nadu, India
| | | | | | - Adel A H Mahmoud
- National Neuroscience Institute, Riyadh, Kingdom of Saudi Arabia
| | - Ali D AlOtaibi
- King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Aman P S Sohal
- Neuropedia Children's Neuroscience Center, Dubai, United Arab Emirates
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Hirohata S, Tanaka K. Differential expression of antibodies to NMDA receptor in anti-NMDA receptor encephalitis and in neuropsychiatric systemic lupus erythematosus. Lupus Sci Med 2019; 6:e000359. [PMID: 31798919 PMCID: PMC6861108 DOI: 10.1136/lupus-2019-000359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 01/17/2023]
Abstract
Objective Anti-NMDA receptor encephalitis is the most prevalent autoimmune encephalitis having characteristic clinical features with autoantibodies against tetrameric transmembrane channels composed of combinations of NR1 subunits of NMDA receptors with NR2 subunits, which are detected by cell-based assay (anti-NR1/NR2). On the other hand, antibodies against the linear epitope in NR2 subunit (anti-NR2) have been shown to be expressed in patients with diffuse psychiatric/neuropsychological syndromes of neuropsychiatric SLE (diffuse NPSLE). However, it has not been explored whether anti-NR1/NR2 might be detected in NPSLE, nor has it been clear whether anti-NR2 might have cross-reactivity with anti-NR1/NR2. The current study was therefore performed to explore the prevalence of anti-NR1/NR2 in NPSLE. Methods Serum specimens were obtained from 31 patients with NPSLE (22 with diffuse NPSLE and 9 with neurological syndromes or polyneuropathy) and from 18 normal healthy subjects. Anti-NR2 and anti-NR1/NR2 were measured by ELISA and cell-based assay, respectively. The positivity for anti-NR2 was defined by a value exceeding mean+2 SD of normal healthy subjects. Results Anti-NR2 was positive in the sera of 19 of 31 patients with NPSLE (in 15 of 22 patients with diffuse NPSLE). By contrast, anti-NR1/NR2 was positive only in 2 of 31 patients with NPSLE (in 2 of 22 patients with diffuse SLE). The positivity for anti-NR1/NR2 was not correlated with anti-NR2 values. Conclusions These results demonstrate that the prevalence of anti-NR1/NR2 is extremely low in NPSLE. Moreover, the data also confirm that anti-NR2 antibodies do not have cross-reactivity with anti-NR1/NR2.
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Affiliation(s)
- Shunsei Hirohata
- Rheumatology, Nobuhara Hospital and Institute of Biomechanics, Tatsuno, Hyogo, Japan.,Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Keiko Tanaka
- Animal Model Development, Niigata University Brain Research Institute, Niigata, Japan
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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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Abstract
OBJECTIVES Anti-N-methyl-D-aspartate receptor encephalitis is considered an immune-mediated form of encephalitis with paraneoplastic and nonparaneoplastic forms. Delay in recognition is common and patients typically present to the ICU without a diagnosis or with complications following a delayed diagnosis. The aim of this review is to provide a focused overview for the ICU clinician regarding presentation, diagnosis, and critical care management. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION PubMed database search with manual review of articles involving anti-N-methyl-D-aspartate receptor encephalitis. DATA SYNTHESIS Anti-N-methyl-D-aspartate receptor encephalitis is increasingly encountered in the ICU. The cascade of events initiating anti-N-methyl-D-aspartate receptor antibody formation may involve an infectious trigger particularly in the setting of teratoma. Following a prodrome, most patients develop psychiatric symptoms followed by movement disorder. Classical, psychiatric, and catatonic phenotypes may be distinguished based on the presence and severity of symptoms. Early immunotherapy and low initial cerebrospinal fluid inflammation are independent predictors of positive outcomes in ICU patients. Concomitant organ failure, status epilepticus, and the identification of a tumor did not influence outcome in critically ill patients. Supportive care in the ICU includes management of various manifestations of dyskinesia, status epilepticus, autonomic disorders, and the need for general sedation. Common treatment strategies and limitations are discussed including the emerging role of bortezomib. CONCLUSIONS Intensivists should be familiar with the presentation and management of anti-N-methyl-D-aspartate receptor encephalitis. Early diagnosis and immediate implementation of steroids, immunoglobulins, and/or plasmapheresis and immune therapy are associated with a good neurologic outcome although response may be delayed. The selection and timing of second-line immune therapy requires further study.
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17
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Schermann H, Ponomareva IV, Maltsev VG, Yakushev KB, Sherman MA. Clinical variants of limbic encephalitis. SAGE Open Med Case Rep 2019; 7:2050313X19846042. [PMID: 31105945 PMCID: PMC6501490 DOI: 10.1177/2050313x19846042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 04/03/2019] [Indexed: 01/15/2023] Open
Abstract
The clinical picture of immunomediator disorders of the central nervous system resulting from autoimmune or paraneoplastic processes is often represented by the limbic symptom complex or limbic encephalitis. The article gives a brief description of these conditions, allocated to a separate nosological group in 2007. The symptoms of limbic encephalitis include mental disorders and epileptic seizures of both convulsive and non-convulsive spectrum, up to epileptic status. Four clinical cases representative of different variants of limbic encephalitis are presented in this study, along with the discussion of epidemiology, differential diagnostics, and generally accepted patient management strategies. The diagnosis of limbic encephalitis was made on clinical grounds alone in three cases and on the presence of antibodies to N-Methyl-d-aspartic acid receptors in one case. A combination of glucocorticoid pulse therapy with prolonged use of valproic acid was successfully applied for the treatment of limbic encephalitis with non-convulsive epileptic status. Plasmapheresis was used for the treatment of limbic encephalitis with recurrent focal non-motor attacks with and without loss of consciousness, as well as for limbic encephalitis with focal motor attacks. Presented cases emphasize the need to increase the awareness of physicians of various specialties to autoimmune disorders of the nervous system. In addition, it highlights the necessity of complete diagnostic workup for a patient with impaired consciousness of unclear etiology.
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Affiliation(s)
- Haggai Schermann
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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18
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Shan F, Long Y, Qiu W. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Review of the Literature. Front Immunol 2018; 9:2802. [PMID: 30568655 PMCID: PMC6290896 DOI: 10.3389/fimmu.2018.02802] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/13/2018] [Indexed: 11/13/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is an autoimmune disease of the nervous system first defined in 2016. GFAP autoantibody, especially IgG that binds to GFAPα, has been reported in the cerebrospinal fluid (CSF) and serum of patients with GFAP astrocytopathy. The positive predictive value of GFAP antibody in the CSF is higher than in the serum. Tissue-based assay (TBA) and cell-based assay (CBA) are both recommended methods for the detection of GFAP antibody. GFAP astrocytopathy is accompanied by neoplasms, but the relationship between virus infection and GFAP astrocytopathy is unclear. GFAP antibody itself does not induce pathological changes; it is only a biomarker for the process of immune inflammation. The pathology of GFAP astrocytopathy in humans is heterogeneous. GFAP astrocytopathy is commonly diagnosed in individuals over 40 years old and most patients have an acute or subacute onset. Clinical manifestations include fever, headache, encephalopathy, involuntary movement, myelitis, and abnormal vision. Lesions involve the subcortical white matter, basal ganglia, hypothalamus, brainstem, cerebellum, and spinal cord. The characteristic MRI feature is brain linear perivascular radial gadolinium enhancement in the white matter perpendicular to the ventricle. Currently, there are no uniform diagnostic criteria or consensus for GFAP astrocytopathy and coexisting neural autoantibodies detected in the same patient make the diagnosis difficult. A standard treatment regimen is yet to be developed. Most GFAP astrocytopathy patients respond well to steroid therapy although some patients are prone to relapse or even die.
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Affiliation(s)
- Fulan Shan
- Department of Neurology, Zengcheng District People's Hospital of Guangzhou, Guangzhou, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Collaborative Innovation Center for Neurogenetics and Channelopathies, Institute of Neuroscience and The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Gomes Ferreira M, Lapresa Alcalde V, García Sánchez MH, Hernández Hernández L, Doyague Sánchez MJ. Successful treatment of anti-NMDA receptor encephalitis with early teratoma removal and plasmapheresis: A case report. Medicine (Baltimore) 2018; 97:e11325. [PMID: 30075499 PMCID: PMC6081068 DOI: 10.1097/md.0000000000011325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE This report describes a Successful treatment of anti-NMDA receptor encephalitis with early teratoma removal and plasmapheresis. PATIENT CONCERNS We present a 31-year-old Caucasian nulliparous patient who was admitted as an emergency with general illness status accompanied by holocranial cephalalgia and fever. DIAGNOSES The previous symptoms were followed by disorientation, persecutory delusion, incoherent language, and tonic-clonic seizure. INTERVENTIONS The patient was admitted in the intensive care unit (ICU) with Glasgow score 7. OUTCOMES Most of complementary exams (brain CT, brain MRI, blood analysis, PCR for virus on CSF) were normal except CSF leucocytosis and hyperproteinorrhachia. An abdominopelvic ultrasound revealed a 5-cm solid-cystic tumor in the left adnexal region, suggestive of teratoma. At that stage, the possibility of autoimmune encephalitis was considered, and confirmed later. LESSONS This disease can only be successfully treated with fast surgical intervention and an early implementation of immunosuppressive therapies. The optimal timing of initiation and duration of therapeutic plasma exchange necessary to achieve good outcomes in patients with NMDAR remains unknown. This case report intends to increase awareness about the importance of early surgical treatment and early implementation of this potentially life-saving therapy and of continuing the treatment until complete remission of symptoms.
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Affiliation(s)
- Monica Gomes Ferreira
- Department of Obstetrics and Gynecology, University Clinic Hospital of Salamanca, Salamanca
- Biomedical Research Institute of Salamanca (IBSAL)—University Hospital of Salamanca, Spain
| | - Victoria Lapresa Alcalde
- Department of Obstetrics and Gynecology, University Clinic Hospital of Salamanca, Salamanca
- Biomedical Research Institute of Salamanca (IBSAL)—University Hospital of Salamanca, Spain
| | | | - Lourdes Hernández Hernández
- Department of Obstetrics and Gynecology, University Clinic Hospital of Salamanca, Salamanca
- Biomedical Research Institute of Salamanca (IBSAL)—University Hospital of Salamanca, Spain
| | - María José Doyague Sánchez
- Department of Obstetrics and Gynecology, University Clinic Hospital of Salamanca, Salamanca
- Biomedical Research Institute of Salamanca (IBSAL)—University Hospital of Salamanca, Spain
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20
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Mitra AD, Afify A. Ovarian teratoma associated Anti-N-methyl-D-aspartate receptor encephalitis: a difficult diagnosis with a favorable prognosis. AUTOPSY AND CASE REPORTS 2018; 8:e2018019. [PMID: 29780755 PMCID: PMC5953185 DOI: 10.4322/acr.2018.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/14/2018] [Indexed: 12/28/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a recently described
auto-immune and paraneoplastic encephalitis with prominent neuropsychiatric manifestations
affecting young adults with ovarian teratoma. The availability of a novel assay to measure
these antibodies might suggest an etiology for this potentially life-threatening disease,
which if early recognized can be treated promptly with surgery with chances of a good clinical
outcome. Reported prognostic indicators for a good outcome depend on the presence of a tumor,
prompt treatment and no admission to an intensive care unit. However, due to the rarity and
unawareness of this disease, the diagnosis may be delayed as primary psychiatric disorders,
and infective encephalitis is taken more into consideration and ruled out first. Here we report
a case of anti-NMDAR encephalitis in a 22-year-old female prompted by an ovarian teratoma
with a gradual and complete resolution of symptoms after surgical excision of the teratoma
and immunomodulating therapies.
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Affiliation(s)
- Ananya Datta Mitra
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine . Sacramento, CA , USA
| | - Alaa Afify
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine . Sacramento, CA , USA
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21
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Chandra SR, Padmanabha H, Koti N, Kalya Vyasaraj K, Mailankody P, Pai AR. N-Methyl-D-Aspartate Encephalitis our Experience with Diagnostic Dilemmas, Clinical Features, and Outcome. J Pediatr Neurosci 2018; 13:423-428. [PMID: 30937083 PMCID: PMC6413609 DOI: 10.4103/jpn.jpn_96_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction A neuropsychiatric syndrome characterized by a wide spectrum of clinical manifestations. It is seen in patients with antibodies against NR1-NR2 heteromers of the NMDA receptor. As the spectrum is mainly psychiatric most patients are treated as psychiatric disease resulting in huge diagnostic delay. Patient and methods Here we describe 29 patients with NMDA encephalitis seen by the authors in the last five years. Percentage of Transfected cells showing granular cytoplasmic florescence was considered for positivity and severity both in CSF and serum. Their presenting diagnosis, clinical features and the dilemmas, alarming gaps, laboratory data, response to treatment and relapses are discussed. Observations All patients presented with a spectrum of psychiatric symptoms varying from panic to severe aggression, seizures, chorea, hemiplegia, catatonia, mitgehen, mutism, delirium, mania and memory problems. EEG is invariably abnormal as against imaging. Conclusion NMDA receptor mediated encephalitis should be suspected in all children and females of adolescent age with refractory neuropsychiatric syndrome. Both CSF and serum should be tested and regular follow up for relapses and neoplasms is mandatory.
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Affiliation(s)
- Sadanandavalli R Chandra
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Hansashree Padmanabha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Neeraja Koti
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Kishore Kalya Vyasaraj
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Pooja Mailankody
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Anupama R Pai
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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22
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Abstract
NMDAR encephalitis is a common cause of autoimmune encephalitis, predominantly affecting young adults. Current data supports the idea that autoantibodies targeting NMDARs are responsible for disease pathogenesis. While these autoantibodies occur in the setting of underlying malignancy in approximately half of all patients, initiating factors for the autoimmune response in the remainder of patients are unclear. While there is increasing evidence supporting viral triggers such as herpes simplex encephalitis, this association and the mechanism of action have not yet been fully described. Although the majority of patients achieve good outcomes, those without an underlying tumor consistently show worse outcomes, prolonged recovery, and more frequent relapses. The cloning of patient-specific autoantibodies from affected individuals has raised important questions as to disease pathophysiology and clinical heterogeneity. Further advances in our understanding of this disease and underlying triggers are necessary to develop treatments which improve outcomes in patients presenting in the absence of tumors.
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Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis
Center, Division of Neuroimmunology and Neuroinfectious Diseases,
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, United States
| | - Krishma Adatia
- Johns Hopkins Encephalitis
Center, Division of Neuroimmunology and Neuroinfectious Diseases,
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, United States
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23
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Liang Z, Yang S, Sun X, Li B, Li W, Liu Z, Yu G. Teratoma-associated anti-NMDAR encephalitis: Two cases report and literature review. Medicine (Baltimore) 2017; 96:e9177. [PMID: 29245365 PMCID: PMC5728980 DOI: 10.1097/md.0000000000009177] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE This study aimed to discuss the pathogenesis, clinical manifestation, diagnosis, and treatment of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. CASE REPORT The diagnosis and treatment of 2 cases with teratoma-associated anti-NMDAR encephalitis were summarized and the clinical data of patients reported by domestic and international studies were reviewed in this study. The 2 cases were both adolescent females who showed mental abnormalities as their main clinical manifestation. The patients were positive for anti-NMDAR antibody in their serum and cerebrospinal fluid, and gynecologic ultrasound detected ovarian teratoma. After diagnosis, the patients underwent teratoma resection, followed by pulse therapy of hormones and gamma globulin. Chemotherapy was performed to prevent tumor recurrence, and patients were in a stable condition. CONCLUSIONS Teratoma-associated anti-NMDAR encephalitis is commonly seen in young women. The clinical manifestation of this disease is nonspecific, and the patients mainly have fever, psychosis, and seizure. Tumor resection and immune therapy are effective treatment strategies, and standardized chemotherapy should also be performed to prevent recurrence.
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Affiliation(s)
- Zhigang Liang
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
| | - Shaowan Yang
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
| | - Xuwen Sun
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
| | - Bing Li
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
| | - Wei Li
- Department of Neurology, Beijing Tiantan Hospital, Beijing, P. R. China
| | - Zhuli Liu
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
| | - Guoping Yu
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong
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Anti-N-Methyl-D-aspartate Receptor Encephalitis: A Severe, Potentially Reversible Autoimmune Encephalitis. Mediators Inflamm 2017; 2017:6361479. [PMID: 28698711 PMCID: PMC5494059 DOI: 10.1155/2017/6361479] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/04/2017] [Indexed: 02/06/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is potentially lethal, but it is also a treatable autoimmune disorder characterized by prominent psychiatric and neurologic symptoms. It is often accompanied with teratoma or other neoplasm, especially in female patients. Anti-NMDAR antibodies in cerebrospinal fluid (CSF) and serum are characteristic features of the disease, thereby suggesting a pathogenic role in the disease. Here, we summarize recent studies that have clearly documented that both clinical manifestations and the antibodies may contribute to early diagnosis and multidisciplinary care. The clinical course of the disorder is reversible and the relapse could occur in some patients. Anti-NMDAR encephalitis coexisting with demyelinating disorders makes the diagnosis more complex; thus, clinicians should be aware of the overlapping diseases.
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25
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Vasenina EE, Levin OS, Gankina OA, Chimagomedova AS, Levikov DI. Autoimmune anti-NMDA-R encephalitis. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:110-116. [DOI: 10.17116/jnevro201711721110-116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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26
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Boujoual M, Hakimi I, Kassidi F, Akhoudad Y, Sahel N, Rkiouak A, Allaoui M, Chahdi H, Oukabli M, Kouach J, Moussaoui DR, Dehayni M. Paraneoplastic syndromes revealing ovarian teratoma in young and menopausal women: report of two cases. Pan Afr Med J 2016; 24:161. [PMID: 27795759 PMCID: PMC5072828 DOI: 10.11604/pamj.2016.24.161.6743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 04/06/2016] [Indexed: 12/04/2022] Open
Abstract
Paraneoplastic syndromes are a heterogeneous group of clinical and biological manifestations caused by underling neoplasms. They can reveal ovarian teratoma which express neuroendocrine proteins, or contain mature or immature neural tissue inducing an autoimmune response. The etiological investigation is then crucial to early identification of the tumor in order to optimize the prognosis and to limit neurological sequelae. In case of ovarian teratoma, management is essentially based on surgical resection sometimes associated with immunotherapie. We report two new cases of ovarian teratoma revealed by paraneoplastic syndromes in young and menopausal woman.
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Affiliation(s)
- Majdouline Boujoual
- Department of Gynecology-Obstetric, University of Medicine Tangier, Military Training Hospital Med V, Rabat, Maroc
| | - Ihsan Hakimi
- Department of Gynecology-Obstetric, Military Training Hospital Med V, Rabat, Maroc
| | - Farid Kassidi
- Department of Gynecology-Obstetric, Military Training Hospital Med V, Rabat, Maroc
| | - Youssef Akhoudad
- Department of Internal Medicine, Military Training Hospital Med V, Rabat, Maroc
| | - Nawal Sahel
- Department of Internal Medicine, Military Training Hospital Med V, Rabat, Maroc
| | - Adil Rkiouak
- Department of Internal Medicine, Military Training Hospital Med V, Rabat, Maroc
| | - Mohamed Allaoui
- Department of Pathology, Military Training Hospital Med V, Rabat, Maroc
| | - Hafsa Chahdi
- Department of Pathology, Military Training Hospital Med V, Rabat, Maroc
| | - Mohamed Oukabli
- Department of Pathology, Military Training Hospital Med V, Rabat, Maroc
| | - Jaouad Kouach
- Department of Gynecology-Obstetric, Military Training Hospital Med V, Rabat, Maroc
| | | | - Mohamed Dehayni
- Department of Gynecology-Obstetric, Military Training Hospital Med V, Rabat, Maroc
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27
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Peng Y, Liu X, Pan S, Xie Z, Wang H. Anti-N-methyl-D-aspartate receptor encephalitis associated with intracranial Angiostrongylus cantonensis infection: a case report. Neurol Sci 2016; 38:703-706. [PMID: 27778112 DOI: 10.1007/s10072-016-2718-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/15/2016] [Indexed: 12/19/2022]
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a recently described paraneoplastic syndrome with prominent neuropsychiatric symptoms. Many of these cases are associated with neoplasma especially teratoma. In addition, a few of cases with anti-NMDAR antibodies triggered by viral infection have been reported, but never by parasitic infection. Here, we report a novel case of NMDA receptor encephalitis in a 51-year-old male related to the development of anti-NMDAR antibodies triggered by Angiostrongylus cantonensis infection.
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Affiliation(s)
- Yu Peng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaojia Liu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zuoshan Xie
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Honghao Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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28
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Tantipalakorn C, Soontornpun A, Pongsuvareeyakul T, Tongsong T. Rapid recovery from catastrophic paraneoplastic anti-NMDAR encephalitis secondary to an ovarian teratoma following ovarian cystectomy. BMJ Case Rep 2016; 2016:bcr-2016-216484. [PMID: 27511754 DOI: 10.1136/bcr-2016-216484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This report is aimed to describe a life-threatening case of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis secondary to ovarian teratoma with rapid recovery in 1 day after the removal of the tumour. A 23-year-old woman presented with sudden headache, personality changes and seizure. After neurological assessment, limbic or herpes encephalitis was provisionally diagnosed and treated with intravenous immunoglobulin, acyclovir and steroids. The patient had progressive severe neurological symptoms, requiring prolonged intubation and mechanical ventilation. An anti-NMDAR antibody test revealed positive in serum and cerebrospinal fluid at 3 weeks of admission. Pelvic ultrasound examination and CT scan revealed bilateral small ovarian teratomas. Bilateral ovarian cystectomy was performed by open surgery. The patient showed rapid improvement and no longer needed intubation 2 days after the operation. In conclusion, we described a catastrophic case of ovarian teratoma-associated encephalitis with delayed diagnosis but rapid recovery after ovarian cystectomy. This information can probably be helpful to neurologists and gynaecologists.
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Affiliation(s)
| | | | | | - Theera Tongsong
- Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand
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Suppiej A, Nosadini M, Zuliani L, Pelizza MF, Toldo I, Bertossi C, Tison T, Zoccarato M, Marson P, Giometto B, Dale RC, Sartori S. Plasma exchange in pediatric anti-NMDAR encephalitis: A systematic review. Brain Dev 2016; 38:613-22. [PMID: 26926399 DOI: 10.1016/j.braindev.2016.01.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/19/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To clarify the most frequent modalities of use of plasma exchange (PE) in pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis and to establish the most effective association with other immunotherapies. METHODS Systematic literature review on PE in pediatric anti-NMDAR encephalitis (2007-2015). RESULTS Seventy-one articles were included (mostly retrospective), reporting a total of 242 subjects (73.2%, 93/127 females; median age at onset 12years, range 1-18). Median time to immunotherapy was 21days (range 0-190). In most cases, PE was given with steroids and IVIG (69.5%, 89/128), or steroids only (18%, 23/128); in a minority, it was associated with IVIG only (7%, 9/128), or was the only first-line treatment (5.5%, 7/128). In 54.5% (65/119), PE was the third treatment after steroids and IVIG, in 31.1% (37/119) the second after steroids or IVIG; only in 14.3% (17/119) was it the first treatment. Second-line immunotherapies were administered in 71.9% (100/139). Higher rates of full/substantial recovery at follow-up were observed with immunotherapy given ⩽30days from onset (69.4%, 25/36) compared to later (59.2%, 16/27), and when PE was associated with steroids (66.7%, 70/105) rather than not (46.7%, 7/15). Significant adverse reactions to PE were reported in 6 patients. CONCLUSION Our review disclosed a paucity of quality data on PE in pediatric anti-NMDAR encephalitis. PE use in this condition has been increasingly reported, most often with steroids and IVIG. Despite the limited number of patients, our data seem to confirm the trend towards a better outcome when PE was administered early, and when given with steroids.
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Affiliation(s)
- Agnese Suppiej
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy.
| | - Margherita Nosadini
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Luigi Zuliani
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Maria Federica Pelizza
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Irene Toldo
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Chiara Bertossi
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
| | - Tiziana Tison
- Immunotransfusion Section, University Hospital of Padua, Italy
| | - Marco Zoccarato
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Piero Marson
- Immunotransfusion Section, University Hospital of Padua, Italy
| | - Bruno Giometto
- Department of Neurology, Ospedale Ca' Foncello, Treviso, Italy
| | - Russell C Dale
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Australia
| | - Stefano Sartori
- Pediatric Neurology Unit, Department of Woman's and Child's Health, University Hospital of Padua, Italy
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Lasoff DR, Corbett-Detig J, Sell R, Nolan M, Wardi G. Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department. West J Emerg Med 2016; 17:280-2. [PMID: 27330659 PMCID: PMC4899058 DOI: 10.5811/westjem.2016.2.29554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 11/20/2022] Open
Abstract
Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and often have prolonged hospitalizations and intensive care unit stays. There is little literature in the emergency medicine community regarding this disease process, so we report on a case we encountered in our emergency department to help raise awareness of this disease process.
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Affiliation(s)
- Daniel R Lasoff
- UCSD Medical Center, Department of Emergency Medicine, Division of Medical Toxicology, San Diego, California; VA Medical Center, San Diego, California
| | - Jimmy Corbett-Detig
- UCSD Medical Center, Department of Emergency Medicine, San Diego, California
| | - Rebecca Sell
- UCSD Medical Center, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, San Diego, California
| | - Matthew Nolan
- UCSD Medical Center, Department of Emergency Medicine, San Diego, California
| | - Gabriel Wardi
- UCSD Medical Center, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, San Diego, California
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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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Neiman ES, Panezai S, Salim S, Seyffert M, Leifer LE, Rosenberg M, Chokroverty S. Bulbar and Limb Myorhythmia with "Smooch Sign": A Distinctive Movement Disorder in an Adult Patient with Reversible Anti-NMDA Receptor Encephalitis Associated with an Ovarian Teratoma. Neurodiagn J 2016; 55:149-56. [PMID: 26630807 DOI: 10.1080/21646821.2015.1073069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Anti-N-Methyl-D-Aspartate receptor encephalitis is a recently described entity (Dalmau et al. 2007, 2008) that may present with a variety of complex movements in addition to other features (Kleinig et al. 2008). The purpose of our presentation of such a patient is twofold: (1) to characterize these complex oculo-oro-linguo-masticatory and limb movements with "smooch sign" as myorhythmia, based on a combined clinical and electrophysiological analysis (Masucci et al. 1984); and (2) to document possibly characteristic EEG evolution in the course of observation in our institution for three weeks from diffuse slowing to evolving rhythmic delta activity, which may represent a pattern of electrographic seizure activity.
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Landek-Salgado MA, Faust TE, Sawa A. Molecular substrates of schizophrenia: homeostatic signaling to connectivity. Mol Psychiatry 2016; 21:10-28. [PMID: 26390828 PMCID: PMC4684728 DOI: 10.1038/mp.2015.141] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 02/06/2023]
Abstract
Schizophrenia (SZ) is a devastating psychiatric condition affecting numerous brain systems. Recent studies have identified genetic factors that confer an increased risk of SZ and participate in the disease etiopathogenesis. In parallel to such bottom-up approaches, other studies have extensively reported biological changes in patients by brain imaging, neurochemical and pharmacological approaches. This review highlights the molecular substrates identified through studies with SZ patients, namely those using top-down approaches, while also referring to the fruitful outcomes of recent genetic studies. We have subclassified the molecular substrates by system, focusing on elements of neurotransmission, targets in white matter-associated connectivity, immune/inflammatory and oxidative stress-related substrates, and molecules in endocrine and metabolic cascades. We further touch on cross-talk among these systems and comment on the utility of animal models in charting the developmental progression and interaction of these substrates. Based on this comprehensive information, we propose a framework for SZ research based on the hypothesis of an imbalance in homeostatic signaling from immune/inflammatory, oxidative stress, endocrine and metabolic cascades that, at least in part, underlies deficits in neural connectivity relevant to SZ. Thus, this review aims to provide information that is translationally useful and complementary to pathogenic hypotheses that have emerged from genetic studies. Based on such advances in SZ research, it is highly expected that we will discover biomarkers that may help in the early intervention, diagnosis or treatment of SZ.
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Affiliation(s)
- M A Landek-Salgado
- Department of Psychiatry, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - T E Faust
- Department of Psychiatry, John Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neuroscience, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Sawa
- Department of Psychiatry, John Hopkins University School of Medicine, Baltimore, MD, USA
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34
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Abstract
Over the last 15 years it has become clear that rare but highly recognizable diseases of the central nervous system (CNS), including newly identified forms of limbic encephalitis and other encephalopathies, are likely to be mediated by antibodies (Abs) to CNS proteins. The Abs are directed against membrane receptors and ion channel-associated proteins that are expressed on the surface of neurons in the CNS, such as N-methyl D-aspartate receptors and leucine-rich, glioma inactivated 1 protein and contactin-associated protein like 2, that are associated with voltage-gated potassium channels. The diseases are not invariably cancer-related and are therefore different from the classical paraneoplastic neurological diseases that are associated with, but not caused by, Abs to intracellular proteins. Most importantly, the new antibody-associated diseases almost invariably respond to immunotherapies with considerable and sometimes complete recovery, and there is convincing evidence of their pathogenicity in the relatively limited studies performed so far. Treatments include first-line steroids, intravenous immunoglobulins, and plasma exchange, and second-line rituximab and cyclophosphamide, followed in many cases by steroid-sparing agents in the long-term. This review focuses mainly on N-methyl D-aspartate receptor- and voltage-gated potassium channel complex-related Abs in adults, the clinical phenotypes, and treatment responses. Pediatric cases are referred to but not reviewed in detail. As there have been very few prospective studies, the conclusions regarding immunotherapies are based on retrospective studies.
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Affiliation(s)
- Matteo Gastaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- University of Pavia, Pavia, Italy.
| | - Anaïs Thouin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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35
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Zhou SX, Yang YM. Anti-N-methyl-D-aspartate receptor encephalitis with occult ovarian teratoma: a case report. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:15474-15478. [PMID: 26823917 PMCID: PMC4713703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
A 31-year-old female was admitted with headache, memory disturbance, abnormal behavior, incontinence, confusion, complex partial seizures, decreased oxygen saturation and increased temperature. Anti-NMDAR antibodies were positive in serum and cerebrospinal fluid. Subsequently, a regimen of immunotherapy that included intravenous immunoglobulins, methylprednisolone, plasma exchange and their combinations were used. But the treatment was ineffective. Though both transvaginal ultrasonography and abdominal CT scan contrast revealed left ovarian cyst, the patient had left oophorectomy. And during surgery we found a small cyst mass contained fat-like liquid with air in her left ovarian. Pathological examination demonstrated mature cystic teratoma accompanied with brain tissue. She has made gradual and steady improvement after surgery, but not fully recovery. By combining this case with previous studies of others, we further discuss the clinical characteristics, treatment and prognosis of the disease.
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Affiliation(s)
- Shi-Xian Zhou
- Department of Geriatrics, The First Affiliated Hospital, School of Medicine, Zhejiang University Hangzhou 310003, Zhejiang, China
| | - Yun-Mei Yang
- Department of Geriatrics, The First Affiliated Hospital, School of Medicine, Zhejiang University Hangzhou 310003, Zhejiang, China
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36
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Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is considered a rare autoimmune disorder usually caused by an ovarian teratoma. The disease is clinically characterized by neuropsychiatric symptoms followed by intractable seizures and hypoventilation, and it is fatal if left untreated. CASE We present a case of anti-NMDAR encephalitis with classical features in a young woman whose ultimate diagnosis and treatment were delayed because of multiple avoidable circumstances that were recognized only in retrospect. CONCLUSION We believe that this disorder is actually more common than reported. Anti-NMDAR encephalitis must be considered as part of the differential diagnosis in any young woman presenting with new onset psychiatric symptoms. In young women with an acute decrease in their level of consciousness, prompt and continued surveillance for the presence of an underlying tumour should be undertaken, especially when there is a delayed response to empiric treatment.
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37
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Imai K, Fukuda T, Wada T, Kawanishi M, Yamauchi M, Hashiguchi Y, Ichimura T, Yasui T, Sumi T. Complete recovery from paraneoplastic anti-NMDAR encephalitis associated with a small ovarian teratoma following a laparoscopic salpingo-oophorectomy: A case report. Exp Ther Med 2015; 9:1723-1726. [PMID: 26136883 DOI: 10.3892/etm.2015.2344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 02/19/2015] [Indexed: 12/24/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a severe but treatment-responsive disorder, initially identified in young women with an ovarian teratoma. Symptoms include mood, behavior and personality irregularities that resemble acute psychosis. The present study reports the rare case of a patient with anti-NMDAR encephalitis and severe neurological symptoms, that exhibited a rapid recovery following a laparoscopic salpingo-oophorectomy. The 39-year-old woman was admitted to the Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine (Osaka, Japan) with a 5-day history of fever and stomach ache. One week later, the patient developed hallucinations and emotional lability. Initially, a diagnosis of limbic or herpes encephalitis was considered; thus, the patient was administered acyclovir and received steroid pulse therapy. However, the patient subsequently developed apnea, and in response, a tracheal intubation, mechanical ventilation and plasmapheresis were performed. Anti-NMDAR encephalitis was subsequently considered as a diagnosis and mediastinal and pelvic computed tomography (CT) examinations were conducted to detect for the presence of a teratoma. A 24×24-mm cystic lesion was identified in the pelvis from an abdominal CT scan and the lesion appeared to be an ovarian teratoma. In addition, serum and cerebrospinal fluid samples were collected, and were found to test positive for anti-NMDAR antibodies. A laparoscopic salpingo-oophorectomy was performed, which resulted in rapid improvement of the patients mental symptoms, followed by a complete recovery.
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Affiliation(s)
- Kenji Imai
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Takeshi Fukuda
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Takuma Wada
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Masaru Kawanishi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Makoto Yamauchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Yasunori Hashiguchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Tomoyuki Ichimura
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Tomoyo Yasui
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
| | - Toshiyuki Sumi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan
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Sankowski R, Mader S, Valdés-Ferrer SI. Systemic inflammation and the brain: novel roles of genetic, molecular, and environmental cues as drivers of neurodegeneration. Front Cell Neurosci 2015; 9:28. [PMID: 25698933 PMCID: PMC4313590 DOI: 10.3389/fncel.2015.00028] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 01/15/2015] [Indexed: 12/20/2022] Open
Abstract
The nervous and immune systems have evolved in parallel from the early bilaterians, in which innate immunity and a central nervous system (CNS) coexisted for the first time, to jawed vertebrates and the appearance of adaptive immunity. The CNS feeds from, and integrates efferent signals in response to, somatic and autonomic sensory information. The CNS receives input also from the periphery about inflammation and infection. Cytokines, chemokines, and damage-associated soluble mediators of systemic inflammation can also gain access to the CNS via blood flow. In response to systemic inflammation, those soluble mediators can access directly through the circumventricular organs, as well as open the blood–brain barrier. The resulting translocation of inflammatory mediators can interfere with neuronal and glial well-being, leading to a break of balance in brain homeostasis. This in turn results in cognitive and behavioral manifestations commonly present during acute infections – including anorexia, malaise, depression, and decreased physical activity – collectively known as the sickness behavior (SB). While SB manifestations are transient and self-limited, under states of persistent systemic inflammatory response the cognitive and behavioral changes can become permanent. For example, cognitive decline is almost universal in sepsis survivors, and a common finding in patients with systemic lupus erythematosus. Here, we review recent genetic evidence suggesting an association between neurodegenerative disorders and persistent immune activation; clinical and experimental evidence indicating previously unidentified immune-mediated pathways of neurodegeneration; and novel immunomodulatory targets and their potential relevance for neurodegenerative disorders.
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Affiliation(s)
- Roman Sankowski
- Elmezzi Graduate School of Molecular Medicine , Manhasset, NY , USA ; Feinstein Institute for Medical Research , Manhasset, NY , USA
| | - Simone Mader
- Feinstein Institute for Medical Research , Manhasset, NY , USA
| | - Sergio Iván Valdés-Ferrer
- Elmezzi Graduate School of Molecular Medicine , Manhasset, NY , USA ; Feinstein Institute for Medical Research , Manhasset, NY , USA ; Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , México City , Mexico
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Tachibana N, Kinoshita M, Kametani F, Tanaka K, Une Y, Komatsu Y, Kobayashi Y, Ikeda SI. Expression of N-Methyl-D-Aspartate Receptor Subunits in the Bovine Ovum: Ova as a Potential Source of Autoantigens Causing Anti-NMDAR Encephalitis. TOHOKU J EXP MED 2015; 235:223-31. [DOI: 10.1620/tjem.235.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Michiaki Kinoshita
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine
| | - Fuyuki Kametani
- Department of Dementia and Higher Brain Function, Tokyo Metropolitan Institute of Medical Science
| | - Keiko Tanaka
- Department of Neurology, Kanazawa Medical University
- Department of Life Science, Medical Research Institute, Kanazawa Medical University
| | - Yumi Une
- Laboratory of Veterinary Pathology, School of Veterinary Medicine, Azabu University
| | | | - Yukihiro Kobayashi
- Department of Laboratory Medicine, Shinshu University School of Medicine
| | - Shu-ichi Ikeda
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine
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Davydovskaya MV, Boyko AN, Beliaeva IA, Martynov MY, Gusev EI. Autoimmune encephalitis. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:95-101. [DOI: 10.17116/jnevro20151154195-101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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41
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Chakrabarty B, Tripathi M, Gulati S, Yoganathan S, Pandit AK, Sinha A, Rathi BS. Pediatric anti-N-methyl-D-aspartate (NMDA) receptor encephalitis: experience of a tertiary care teaching center from north India. J Child Neurol 2014; 29:1453-9. [PMID: 24097850 DOI: 10.1177/0883073813494474] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is characterized by acute- or subacute-onset encephalopathy with extrapyramidal, psychiatric, and epileptic manifestations. Diagnosis is confirmed by positive antibodies to NMDA receptor in cerebrospinal fluid and serum. Eleven pediatric cases presented over a 2-year period at a tertiary care teaching hospital in North India. The average age at presentation was 9 years (range: 2.5 to 18 years, median: 10 years) with a slight female predominance (1.2:1). The common modes of presentation were progressive extrapyramidal syndrome with global neuroregression in 45% (5 of 11), epileptiform encephalopathy in 27% (3 of 11), and an overlap between the 2 in 27% (3 of 11). Fifty-eight percent showed significant response to steroids and intravenous immunoglobulin. This entity should be considered in an acute- or subacute-onset encephalopathy if common infectious etiologies are ruled out and there are specific clinical pointers. Early diagnosis and treatment significantly improves the outcome.
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Affiliation(s)
| | | | | | | | | | - Aditi Sinha
- All India Institute of Medical Sciences, New Delhi, India
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42
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Miya K, Takahashi Y, Mori H. Anti-NMDAR autoimmune encephalitis. Brain Dev 2014; 36:645-52. [PMID: 24211006 DOI: 10.1016/j.braindev.2013.10.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/07/2013] [Accepted: 10/10/2013] [Indexed: 01/17/2023]
Abstract
The N-methyl-D-aspartate receptor (NMDAR) is involved in normal physiological and pathological states in the brain. Anti-NMDAR encephalitis is characterized by memory deficits, seizures, confusion, and psychological disturbances in males and females of all ages. This type of encephalitis is often associated with ovarian teratoma in young women, but children are less likely to have tumors. Anti-NMDAR encephalitis is a neuroimmune syndrome in patients with autoantibodies recognizing extracellular epitopes of NMDAR, and the autoantibodies attenuate NMDAR function through the internalization of NMDAR. Following the initial symptoms of inflammation, the patients show the various symptoms such as memory loss, confusion, emotional disturbances, psychosis, dyskinesis, decrease in speech intelligibility, and seizures. About half of these patients improved with immunotherapy including high-dose intravenous corticosteroids and intravenous immunoglobulins is administrated to these patients, but the patients who had no improvement with these therapy require further treatments with rituximab or cyclophosphamide. It is necessary to detect anti-NMDAR antibodies at early stages, because the prognosis of these patients may be improved by early treatment. Recovery is slow, and the patients may have some disturbances in their motor function and cognition. The pathologic mechanism underlying the development of anti-NMDAR encephalitis has been elucidated gradually, but the optimal treatment has not yet been clarified. Further studies are required to clarify in detail the mechanism underlying anti-NMDA encephalitis and to develop effective treatments.
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Affiliation(s)
- Kazushi Miya
- Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan
| | - Yukitoshi Takahashi
- Division of Pediatrics, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka 420-8688, Japan
| | - Hisashi Mori
- Department of Molecular Neuroscience, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama 930-0194, Japan.
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43
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Azizyan A, Albrektson JR, Maya MM, Pressman BD, Moser F. Anti-NMDA encephalitis: an uncommon, autoimmune mediated form of encephalitis. J Radiol Case Rep 2014; 8:1-6. [PMID: 25426239 DOI: 10.3941/jrcr.v8i8.1566] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report an interesting case of a 19 year old female with findings on MRI suggestive of viral encephalitis. An extensive workup was negative for infectious causes and she was subsequently diagnosed with anti-NMDA encephalitis. Anti-NMDA encephalitis is a highly lethal but treatable form of autoimmune encephalitis that has recently been characterized. It is frequently found in young women and associated with an underlying teratoma. Although rare, this diagnosis should be considered in young females for whom a rapid onset of encephalitis cannot be explained by more common causes.
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Affiliation(s)
- Avetis Azizyan
- Department of Radiology, Cedars Sinai Hospital, Los Angeles, USA
| | | | - Marcel M Maya
- Department of Radiology, Cedars Sinai Hospital, Los Angeles, USA
| | - Barry D Pressman
- Department of Radiology, Cedars Sinai Hospital, Los Angeles, USA
| | - Franklin Moser
- Department of Radiology, Cedars Sinai Hospital, Los Angeles, USA
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Hayashi M, Motegi E, Honma K, Masawa N, Sakuta H, Hirata K, Kaji Y, Fukasawa I. Successful Laparoscopic Resection of 7 mm Ovarian Mature Cystic Teratoma Associated with Anti-NMDAR Encephalitis. Case Rep Obstet Gynecol 2014; 2014:618742. [PMID: 24959363 PMCID: PMC4053262 DOI: 10.1155/2014/618742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 04/29/2014] [Indexed: 11/17/2022] Open
Abstract
Anti-NMDAR (N-methyl-D-aspartate receptor) encephalitis is an immune-mediated encephalitis. It has been predominantly described in young women and is commonly associated with an ovarian teratoma. We report a case of anti-NMDAR encephalitis associated with a 7 mm ovarian teratoma that was completely resected by laparoscopic surgery. An 18-year-old woman suddenly presented with personality changes requiring her admission to the department of neurology. After that, she also showed involuntary movements, disturbance of consciousness, and central hypoventilation. As an abdominal image revealed the possibility of a right ovarian teratoma of 5 × 7 mm, a laparoscopic operation was performed. The macroscopic appearance of the right ovary did not show any abnormalities; nevertheless, we performed a partial resection of the right ovary, with reference to the image diagnosis, in order to spare the ovarian reserve. The 22 × 22 mm partially resected ovary contained an intact 5 × 7 mm cystic tumor. The pathological diagnosis was mature cystic teratoma with components of brain tissue. An anti-NMDAR-antibody test proved positive in both serum and cerebrospinal fluid 1 month after the surgery. From these results, she was diagnosed with anti-NMDAR encephalitis. By the administration of cyclophosphamide in addition to the operation, she recovered drastically without any of the symptoms shown before.
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Affiliation(s)
- Masaru Hayashi
- Department of Obstetrics and Gynecology, Teine Keijinkai Hospital, Sapporo 006-8555, Japan
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Tochigi, Japan
| | - Emi Motegi
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Tochigi, Japan
| | - Koichi Honma
- Department of Anatomic and Diagnostic Pathology, Dokkyo Medical University, Tochigi, Japan
| | - Nobuhide Masawa
- Department of Anatomic and Diagnostic Pathology, Dokkyo Medical University, Tochigi, Japan
| | - Hideki Sakuta
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Yasushi Kaji
- Department of Radiology, Dokkyo Medical University, Tochigi, Japan
| | - Ichio Fukasawa
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Tochigi, Japan
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Scott O, Richer L, Forbes K, Sonnenberg L, Currie A, Eliyashevska M, Goez HR. Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis: an unusual cause of autistic regression in a toddler. J Child Neurol 2014; 29:691-4. [PMID: 24092894 DOI: 10.1177/0883073813501875] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Anti N-methyl-d-aspartate (NMDA) receptor encephalitis in children is associated with psychiatric changes, seizures, and dyskinesias. We present the first report of autistic regression in a toddler caused by this entity. A 33-month-old boy presented with decreased appetite, irritability, and insomnia following an upper respiratory tract infection. Over the next few weeks he lost language and social skills, and abnormal movements of his hand developed. Within a month, this patient came to fit the diagnostic criteria for autistic spectrum disorder. Upon investigation, anti-NMDA receptor antibodies were found in the boy's cerebrospinal fluid. He was treated with intravenous immunoglobulins and steroids, resulting in reacquisition of language and social skills and resolution of movements. Our case emphasizes the significance of suspecting anti-NMDA receptor encephalitis as the cause of autistic regression, even in an age group where the diagnosis of autistic spectrum disorder is typically made, and especially when presentation follows a febrile illness.
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Affiliation(s)
- Ori Scott
- 1Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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van Coevorden-Hameete MH, de Graaff E, Titulaer MJ, Hoogenraad CC, Sillevis Smitt PAE. Molecular and cellular mechanisms underlying anti-neuronal antibody mediated disorders of the central nervous system. Autoimmun Rev 2014; 13:299-312. [PMID: 24225076 DOI: 10.1016/j.autrev.2013.10.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 10/30/2013] [Indexed: 12/31/2022]
Abstract
Over the last decade multiple autoantigens located on the plasma membrane of neurons have been identified. Neuronal surface antigens include molecules directly involved in neurotransmission and excitability. Binding of the antibody to the antigen may directly alter the target protein's function, resulting in neurological disorders. The often striking reversibility of symptoms following early aggressive immunotherapy supports a pathogenic role for autoantibodies to neuronal surface antigens. In order to better understand and treat these neurologic disorders it is important to gain insight in the underlying mechanisms of antibody pathogenicity. In this review we discuss the clinical, circumstantial, in vitro and in vivo evidence for neuronal surface antibody pathogenicity and the possible underlying cellular and molecular mechanisms. This review shows that antibodies to neuronal surface antigens are often directed at conformational epitopes located in the extracellular domain of the antigen. The conformation of the epitope can be affected by specific posttranslational modifications. This may explain the distinct clinical phenotypes that are seen in patients with antibodies to antigens that are expressed throughout the brain. Furthermore, it is likely that there is a heterogeneous antibody population, consisting of different IgG subtypes and directed at multiple epitopes located in an immunogenic region. Binding of these antibodies may result in different pathophysiological mechanisms occurring in the same patient, together contributing to the clinical syndrome. Unraveling the predominant mechanism in each distinct antigen could provide clues for therapeutic interventions.
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Affiliation(s)
- M H van Coevorden-Hameete
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - E de Graaff
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - M J Titulaer
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - C C Hoogenraad
- Department of Biology, Division of Cell Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, The Netherlands.
| | - P A E Sillevis Smitt
- Department of Neurology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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Schröder A, Linker RA, Gold R. Plasmapheresis for neurological disorders. Expert Rev Neurother 2014; 9:1331-9. [DOI: 10.1586/ern.09.81] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tabata E, Masuda M, Eriguchi M, Yokoyama M, Takahashi Y, Tanaka K, Yukitake M, Horikawa E, Hara H. Immunopathological Significance of Ovarian Teratoma in Patients with Anti-N-Methyl- D-Aspartate Receptor Encephalitis. Eur Neurol 2013; 71:42-8. [DOI: 10.1159/000353982] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/23/2013] [Indexed: 11/19/2022]
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Wilson JE, Shuster J, Fuchs C. Anti-NMDA receptor encephalitis in a 14-year-old female presenting as malignant catatonia: medical and psychiatric approach to treatment. PSYCHOSOMATICS 2013; 54:585-9. [PMID: 23849593 DOI: 10.1016/j.psym.2013.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 03/05/2013] [Accepted: 03/06/2013] [Indexed: 10/26/2022]
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