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Saliba M, Wilton A, Hagen K, Romanowicz M. A complex case of young child with ADHD, developmental delay who developed seronegative autoimmune encephalitis exacerbated by stimulants. Brain Behav Immun Health 2023; 34:100692. [PMID: 37842135 PMCID: PMC10569956 DOI: 10.1016/j.bbih.2023.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/07/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Autoimmune encephalitis (AE) is a group of disorders characterized by a wide clinical spectrum ranging from the typical limbic encephalitis to more complex neuropsychiatric symptoms including abnormal movements, psychosis, deficits in memory and cognition, dysautonomia, seizures, or coma. Psychiatric symptoms can occur early in the disease progress or manifest during its course. These symptoms are challenging and often slow down the diagnosis of AE. This is a crucial aspect considering that early diagnosis and management of AE are critical for a good outcome. However, there is a lack in studies outlining the exact symptomatology and specific appropriate care that would allow clinicians to achieve an early diagnosis and management. Additionally, AE in children mostly presents with neuropsychiatric symptoms and diagnosis is especially challenging in kids because of their limited capacity in describing their symptoms, the normal childhood behavioral changes and the possibility of a comorbid psychiatric diagnosis. We present a complex case of seronegative AE with comorbid ADHD (Attention Deficit Hyperactivity Disorder) and anxiety in a young six-year-old girl.
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Affiliation(s)
- M. Saliba
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - A. Wilton
- Dept. of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - K. Hagen
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - M. Romanowicz
- Dept. of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Lee K, Mills Z, Cheung P, Cheyne JE, Montgomery JM. The Role of Zinc and NMDA Receptors in Autism Spectrum Disorders. Pharmaceuticals (Basel) 2022; 16:ph16010001. [PMID: 36678498 PMCID: PMC9866730 DOI: 10.3390/ph16010001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
NMDA-type glutamate receptors are critical for synaptic plasticity in the central nervous system. Their unique properties and age-dependent arrangement of subunit types underpin their role as a coincidence detector of pre- and postsynaptic activity during brain development and maturation. NMDAR function is highly modulated by zinc, which is co-released with glutamate and concentrates in postsynaptic spines. Both NMDARs and zinc have been strongly linked to autism spectrum disorders (ASDs), suggesting that NMDARs are an important player in the beneficial effects observed with zinc in both animal models and children with ASDs. Significant evidence is emerging that these beneficial effects occur via zinc-dependent regulation of SHANK proteins, which form the backbone of the postsynaptic density. For example, dietary zinc supplementation enhances SHANK2 or SHANK3 synaptic recruitment and rescues NMDAR deficits and hypofunction in Shank3ex13-16-/- and Tbr1+/- ASD mice. Across multiple studies, synaptic changes occur in parallel with a reversal of ASD-associated behaviours, highlighting the zinc-dependent regulation of NMDARs and glutamatergic synapses as therapeutic targets for severe forms of ASDs, either pre- or postnatally. The data from rodent models set a strong foundation for future translational studies in human cells and people affected by ASDs.
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Endres D, Maier V, Leypoldt F, Wandinger KP, Lennox B, Pollak TA, Nickel K, Maier S, Feige B, Domschke K, Prüss H, Bechter K, Dersch R, Tebartz van Elst L. Autoantibody-associated psychiatric syndromes: a systematic literature review resulting in 145 cases. Psychol Med 2022; 52:1135-1146. [PMID: 32892761 PMCID: PMC9069350 DOI: 10.1017/s0033291720002895] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is an important consideration during the diagnostic work-up of secondary mental disorders. Indeed, isolated psychiatric syndromes have been described in case reports of patients with underlying AE. Therefore, the authors performed a systematic literature review of published cases with AE that have predominant psychiatric/neurocognitive manifestations. The aim of this paper is to present the clinical characteristics of these patients. METHODS The authors conducted a systematic Medline search via Ovid, looking for case reports/series of AEs with antineuronal autoantibodies (Abs) against cell surface/intracellular antigens combined with predominant psychiatric/neurocognitive syndromes. The same was done for patients with Hashimoto encephalopathy/SREAT. Only patients with signs of immunological brain involvement or tumors in their diagnostic investigations or improvement under immunomodulatory drugs were included. RESULTS We identified 145 patients with AE mimicking predominant psychiatric/neurocognitive syndromes. Of these cases, 64% were female, and the mean age among all patients was 43.9 (±22.1) years. Most of the patients had Abs against neuronal cell surface antigens (55%), most frequently against the NMDA-receptor (N = 46). Amnestic/dementia-like (39%) and schizophreniform (34%) syndromes were the most frequently reported. Cerebrospinal fluid changes were found in 78%, electroencephalography abnormalities in 61%, and magnetic resonance imaging pathologies in 51% of the patients. Immunomodulatory treatment was performed in 87% of the cases, and 94% of the patients responded to treatment. CONCLUSIONS Our findings indicate that AEs can mimic predominant psychiatric and neurocognitive disorders, such as schizophreniform psychoses or neurodegenerative dementia, and that affected patients can be treated successfully with immunomodulatory drugs.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frank Leypoldt
- Neuroimmunology Section, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel/Lübeck, Kiel/Lübeck, Germany
| | - Klaus-Peter Wandinger
- Neuroimmunology Section, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein Kiel/Lübeck, Kiel/Lübeck, Germany
| | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Thomas A. Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Basics in NeuromodulationUniversity of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Karl Bechter
- Clinic for Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Rick Dersch
- Department for Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Wright MA, Trandafir CC, Nelson GR, Hersh AO, Inman CJ, Zielinski BA. Diagnosis and Management of Suspected Pediatric Autoimmune Encephalitis: A Comprehensive, Multidisciplinary Approach and Review of Literature. J Child Neurol 2022; 37:303-313. [PMID: 34927485 DOI: 10.1177/08830738211064673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Autoimmune encephalitis is an increasingly recognized entity in children. When treated promptly, favorable outcomes are seen in a majority of pediatric patients. However, recognition of autoimmune encephalitis in young patients is challenging. Once autoimmune encephalitis is suspected, additional difficulties exist regarding timing of treatment initiation and duration of treatment, as evidence to guide management of these patients is emerging. Here, we review available literature regarding pediatric autoimmune encephalitis and present our institution's comprehensive approach to the evaluation and management of the disease. These guidelines were developed through an iterative process involving both pediatric neurologists and rheumatologists.
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Affiliation(s)
- Melissa A Wright
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Cristina C Trandafir
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Gary R Nelson
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Aimee O Hersh
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - C J Inman
- Division of Pediatric Rheumatology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA
| | - Brandon A Zielinski
- Division of Pediatric Neurology, Department of Pediatrics, 14434University of Utah, Salt Lake City, UT, USA.,Department of Neurology, 14434University of Utah, Salt Lake City, UT, USA
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Whiteley P, Marlow B, Kapoor RR, Blagojevic-Stokic N, Sala R. Autoimmune Encephalitis and Autism Spectrum Disorder. Front Psychiatry 2021; 12:775017. [PMID: 34975576 PMCID: PMC8718789 DOI: 10.3389/fpsyt.2021.775017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
The concept of "acquired autism" refers to the hypothesis that amongst the massive heterogeneity that encompasses autism spectrum disorder (ASD) there may be several phenotypes that are neither syndromic nor innate. Strong and consistent evidence has linked exposure to various pharmacological and infective agents with an elevated risk of a diagnosis of ASD including maternal valproate use, rubella and herpes encephalitis. Autoimmune encephalitis (AE) describes a group of conditions characterised by the body's immune system mounting an attack on healthy brain cells causing brain inflammation. The resultant cognitive, psychiatric and neurological symptoms that follow AE have also included ASD or autism-like traits and states. We review the current literature on AE and ASD. Drawing also on associated literature on autoimmune psychosis (AP) and preliminary evidence of a psychosis-linked subtype of ASD, we conclude that AE may either act as a potentially causative agent for ASD, and/or produce symptoms that could easily be mistaken for or misdiagnosed as autism. Further studies are required to discern the connection between AE and autism. Where autism is accompanied by regression and atypical onset patterns, it may be prudent to investigate whether a differential diagnosis of AE would be more appropriate.
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Affiliation(s)
| | - Ben Marlow
- Colchester Hospital, East Suffolk and North Essex NHS Foundation Trust, Colchester, United Kingdom
- The Synapse Centre for Neurodevelopment ESNEFT, Colchester, United Kingdom
| | - Ritika R. Kapoor
- Paediatric Endocrinology, Variety Club Children's Hospital, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Medicine and Life Sciences, King's College London, London, United Kingdom
| | | | - Regina Sala
- Centre for Psychiatry, Wolfson Institute, Barts and The London School of Medicine and Dentistry Queen Mary University of London, London, United Kingdom
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Elshahawi HH, Taha GRA, Azzam HME, El Ghamry RH, Abdelgawad AAM, Elshiekh MAAA. N-Methyl-d-aspartate (NMDA) receptor antibody in relation to autism spectrum disorder (ASD): presence and association with symptom profile. MIDDLE EAST CURRENT PSYCHIATRY 2021. [PMCID: PMC8557968 DOI: 10.1186/s43045-021-00141-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Several studies pointed to immune dysregulation abnormalities linked to autism spectrum disorders (ASD). Of those, several autoantibodies had been identified. Recent findings of N-methyl d-aspartate (NMDA) antibodies in autoimmune encephalitis suggested that it caused symptoms like autistic regression. Thus, the purpose of the study was to test for the presence of anti-NMDAR antibodies in the ASD disorder population and to correlate this with the clinical findings. Results Eighty-seven autistic children, 4–12 years old, were enrolled in the study and were matched with sixty typically developing children used as controls. The diagnosis of cases was confirmed by ADOS-2 and clinical evaluation. None of the control children had positive anti-NMDAR antibodies, while 26.4% (23 children) of the patients’ group were positive for serum anti-NMDA receptor antibodies (> 200 pg/ml, p = 0.0157). The positive anti-NMDAR antibody was statistically correlated with better speech stage (p = 0.017), more severe stereotyped behavior (p ≤ 0.001), and abnormal EEG findings (p = 0.025). Conclusions There is a possibility of the presence of anti-NMDAR antibodies in the autism spectrum disorder population with certain characteristics, especially the severity of the stereotyped behaviors.
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Tarantino S, Averna R, Ruscitto C, Ursitti F, Ferilli MAN, Moavero R, Papetti L, Proietti Checchi M, Sforza G, Balestri M, Grimaldi Capitello T, Vigevano F, Vicari S, Valeriani M. Neuropsychological Sequelae, Quality of Life and Adaptive Behavior in Children and Adolescents with Anti-NMDAR Encephalitis: A Narrative Review. Brain Sci 2021; 11:brainsci11111387. [PMID: 34827386 PMCID: PMC8615663 DOI: 10.3390/brainsci11111387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune illness characterized by a constellation of often severe, but treatable, psychiatric and neurological symptoms. Whereas symptoms such as psychosis and bizarre and abnormal motor behavior are common in adults, pediatric patients typically present with behavioral changes, irritability and sleep dysfunction. The recovery phase is usually slow and may be associated with longstanding adaptive, behavioral and neuropsychological problems. Very few studies explored the cognitive and adaptive sequelae in children with anti-NMDAR encephalitis. The present review article suggests that, although most children and adolescents return to their daily life and previous activities, they may have a low quality of life and show neuropsychological sequelae involving language, memory, especially verbal memory, and attentional resources, even after several months from the hospital discharge. In particular, the available results reveal difficulties in cognitive skills involving executive functions. This impairment is considered the “core” of the cognitive profile of young patients with anti-NMDAR encephalitis. On the other hand, some cognitive skills, such as general intelligence, show good overall recovery over time. Additional neuropsychological research evaluating larger samples, more homogenous methods and longitudinal studies is required.
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Affiliation(s)
- Samuela Tarantino
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
- Correspondence:
| | - Roberto Averna
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Claudia Ruscitto
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
| | - Fabiana Ursitti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Michela Ada Noris Ferilli
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00133 Rome, Italy; (C.R.); (R.M.)
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Laura Papetti
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Proietti Checchi
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Giorgia Sforza
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Martina Balestri
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Teresa Grimaldi Capitello
- Unit of Clinical Psychology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.P.C.); (T.G.C.)
| | - Federico Vigevano
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
| | - Stefano Vicari
- Child and Adolescence Neuropsychiatry Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.A.); (S.V.)
| | - Massimiliano Valeriani
- Department of Neurology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.U.); (M.A.N.F.); (L.P.); (G.S.); (M.B.); (F.V.); (M.V.)
- Center for Sensory-Motor Interaction, Denmark Neurology Unit, Aalborg University, 9100 Aalborg, Denmark
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A Systematic Review and Meta-Analysis of Immunoglobulin G Abnormalities and the Therapeutic Use of Intravenous Immunoglobulins (IVIG) in Autism Spectrum Disorder. J Pers Med 2021; 11:jpm11060488. [PMID: 34070826 PMCID: PMC8229039 DOI: 10.3390/jpm11060488] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental disorder affecting approximately 2% of children in the United States. Growing evidence suggests that immune dysregulation is associated with ASD. One immunomodulatory treatment that has been studied in ASD is intravenous immunoglobulins (IVIG). This systematic review and meta-analysis examined the studies which assessed immunoglobulin G (IgG) concentrations and the therapeutic use of IVIG for individuals with ASD. Twelve studies that examined IgG levels suggested abnormalities in total IgG and IgG 4 subclass concentrations, with concentrations in these IgGs related to aberrant behavior and social impairments, respectively. Meta-analysis supported possible subsets of children with ASD with low total IgG and elevated IgG 4 subclass but also found significant variability among studies. A total of 27 publications reported treating individuals with ASD using IVIG, including four prospective, controlled studies (one was a double-blind, placebo-controlled study); six prospective, uncontrolled studies; 2 retrospective, controlled studies; and 15 retrospective, uncontrolled studies. In some studies, clinical improvements were observed in communication, irritability, hyperactivity, cognition, attention, social interaction, eye contact, echolalia, speech, response to commands, drowsiness, decreased activity and in some cases, the complete resolution of ASD symptoms. Several studies reported some loss of these improvements when IVIG was stopped. Meta-analysis combining the aberrant behavior checklist outcome from two studies demonstrated that IVIG treatment was significantly associated with improvements in total aberrant behavior and irritability (with large effect sizes), and hyperactivity and social withdrawal (with medium effect sizes). Several studies reported improvements in pro-inflammatory cytokines (including TNF-alpha). Six studies reported improvements in seizures with IVIG (including patients with refractory seizures), with one study reporting a worsening of seizures when IVIG was stopped. Other studies demonstrated improvements in recurrent infections, appetite, weight gain, neuropathy, dysautonomia, and gastrointestinal symptoms. Adverse events were generally limited but included headaches, vomiting, worsening behaviors, anxiety, fever, nausea, fatigue, and rash. Many studies were limited by the lack of standardized objective outcome measures. IVIG is a promising and potentially effective treatment for symptoms in individuals with ASD; further research is needed to provide solid evidence of efficacy and determine the subset of children with ASD who may best respond to this treatment as well as to investigate biomarkers which might help identify responsive candidates.
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Kern JK, Geier DA, Mehta JA, Homme KG, Geier MR. Mercury as a hapten: A review of the role of toxicant-induced brain autoantibodies in autism and possible treatment considerations. J Trace Elem Med Biol 2020; 62:126504. [PMID: 32534375 DOI: 10.1016/j.jtemb.2020.126504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/28/2020] [Accepted: 03/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Mercury has many direct and well-recognized neurotoxic effects. However, its immune effects causing secondary neurotoxicity are less well-recognized. Mercury exposure can induce immunologic changes in the brain indicative of autoimmune dysfunction, including the production of highly specific brain autoantibodies. Mercury, and in particular, Thimerosal, can combine with a larger carrier, such as an endogenous protein, thereby acting as a hapten, and this new molecule can then elicit the production of antibodies. METHODS A comprehensive search using PubMed and Google Scholar for original studies and reviews related to autism, mercury, autoantibodies, autoimmune dysfunction, and haptens was undertaken. All articles providing relevant information from 1985 to date were examined. Twenty-three studies were identified showing autoantibodies in the brains of individuals diagnosed with autism and all were included and discussed in this review. RESULTS Research shows mercury exposure can result in an autoimmune reaction that may be causal or contributory to autism, especially in children with a family history of autoimmunity. The autoimmune pathogenesis in autism is demonstrated by the presence of brain autoantibodies (neuroantibodies), which include autoantibodies to: (1) human neuronal progenitor cells; (2) myelin basic protein (MBP); (3) neuron-axon filament protein (NAFP); (4) brain endothelial cells; (5) serotonin receptors; (6) glial fibrillary acidic protein (GFAP); (7) brain derived neurotrophic factor (BDNF); (8) myelin associated glycoprotein (MAG); and (9) various brain proteins in the cerebellum, hypothalamus, prefrontal cortex, cingulate gyrus, caudate putamen, cerebral cortex and caudate nucleus. CONCLUSION Recent evidence suggests a relationship between mercury exposure and brain autoantibodies in individuals diagnosed with autism. Moreover, brain autoantibody levels in autism are found to correlate with both autism severity and blood mercury levels. Treatments to reduce mercury levels and/or brain autoantibody formation should be considered in autism.
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Affiliation(s)
- Janet K Kern
- Institute of Chronic Illnesses, Inc., Silver Spring, MD, USA; CoMeD, Inc., Silver Spring, MD, USA; CONEM US Autism Research Group, Allen, TX, USA.
| | - David A Geier
- Institute of Chronic Illnesses, Inc., Silver Spring, MD, USA; CoMeD, Inc., Silver Spring, MD, USA
| | - Jyutika A Mehta
- Texas Woman's University, Department of Communication Sciences and Disorders, Denton, TX, USA
| | - Kristin G Homme
- CoMeD, Inc., Silver Spring, MD, USA; International Academy of Oral Medicine and Toxicology, Champions Gate, FL, USA
| | - Mark R Geier
- Institute of Chronic Illnesses, Inc., Silver Spring, MD, USA; CoMeD, Inc., Silver Spring, MD, USA
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Shim Y, Kim SY, Kim H, Hwang H, Chae JH, Choi J, Kim KJ, Yum MS, Ko TS, Kim YO, Byeon JH, Lee J, Lee J, Kim JS, Lim BC. Clinical outcomes of pediatric Anti-NMDA receptor encephalitis. Eur J Paediatr Neurol 2020; 29:87-91. [PMID: 33046392 DOI: 10.1016/j.ejpn.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/05/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the clinical features and long-term outcomes of pediatric Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHODS Thirty-two anti-NMDAR encephalitis patients with positive anti-NMDAR antibody test results were recruited. Clinical outcomes were evaluated using the Clinical Assessment Scale in Autoimmune Encephalitis (CASE) and the modified Rankin Scale (mRS). RESULTS The median age of onset was 9.0 years (range, 0.7-17.2 years). Twenty-four patients (75.0%) were female. All patients received first-line immunotherapy including intravenous immunoglobulin and/or steroid therapy. The second-line immunotherapy was administered to 22 patients (68.8%). Clinical outcomes were evaluated in 27 patients who were followed for longer than 6 months after onset, among whom the median follow-up duration was 31.2 months (range, 6.3-82.9 months). The proportion of patients with ≤2 points on the mRS at their 12-month follow-up was 79.2% (19/24). The CASE scores of these 19 patients ranged from 0 to 5, with language and memory deficits accounting for most of these disabilities. When the outcome was assessed according to onset age (<12 years or 12-18 years), the younger group tended to show a slower recovery over their clinical course. CONCLUSIONS Despite overall favorable clinical outcomes, mild cognitive problems, including language and memory, may persist in pediatric anti-NMDAR encephalitis patients. A specific outcome measure, such as CASE, should be adopted to delineate clinical outcomes and aid the development of individualized treatment plans.
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Affiliation(s)
- YoungKyu Shim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hunmin Kim
- Department of Pediatrics, Bundang Seoul National University Hospital, Bundang, Republic of Korea
| | - Hee Hwang
- Department of Pediatrics, Bundang Seoul National University Hospital, Bundang, Republic of Korea
| | - Jong-Hee Chae
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jieun Choi
- Department of Pediatrics, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ki Joong Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Sung Ko
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Ok Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jung Hye Byeon
- Department of Pediatrics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
| | - Jon Soo Kim
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Byung Chan Lim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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11
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Sala R, Amet L, Blagojevic-Stokic N, Shattock P, Whiteley P. Bridging the Gap Between Physical Health and Autism Spectrum Disorder. Neuropsychiatr Dis Treat 2020; 16:1605-1618. [PMID: 32636630 PMCID: PMC7335278 DOI: 10.2147/ndt.s251394] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022] Open
Abstract
Autism spectrum disorder (ASD) is a highly complex and heterogeneous developmental disorder that affects how individuals communicate with other people and relate to the world around them. Research and clinical focus on the behavioural and cognitive manifestations of ASD, whilst important, have obscured the recognition that ASD is also commonly associated with a range of physical and mental health conditions. Many physical conditions appear with greater frequency in individuals with ASD compared to non-ASD populations. These can contribute to a worsening of social communication and behaviour, lower quality of life, higher morbidity and premature mortality. We highlight some of the key physical comorbidities affecting the immune and the gastrointestinal systems, metabolism and brain function in ASD. We discuss how healthcare professionals working with individuals with ASD and parents/carers have a duty to recognise their needs in order to improve their overall health and wellbeing, deliver equality in their healthcare experiences and reduce the likelihood of morbidity and early mortality associated with the condition.
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Affiliation(s)
- Regina Sala
- Centre for Psychiatry, Wolfson Institute, Barts & The London School of Medicine & Dentistry Queen Mary University of London, London, UK
| | | | | | - Paul Shattock
- Education & Services for People with Autism, Sunderland, UK
| | - Paul Whiteley
- Education & Services for People with Autism Research, Sunderland, UK
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12
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Whiteley P, Carr K, Shattock P. Is Autism Inborn And Lifelong For Everyone? Neuropsychiatr Dis Treat 2019; 15:2885-2891. [PMID: 31632036 PMCID: PMC6789180 DOI: 10.2147/ndt.s221901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023] Open
Abstract
Autism or autism spectrum disorder (ASD) is described as a lifelong condition with core behavioural symptoms appearing during infancy or early childhood. Genetic and other effects occurring during the earliest times of life are thought to play a significant contributory role to the presentation of autism, denoting that autism is typically seen as an innate or inborn condition. Such descriptions have, and continue to, define autism research and clinical practice. Inspection of the existing research literature, however, suggests that within the vast heterogeneity of autism, not everyone experiences autism in such a prescribed way. Various reports have observed the presentation of "acquired autism" following a period of typical development. Other findings have documented an abatement of clinically relevant autistic features and related comorbid pathology for some. Such reports offer important insights into the heterogeneity and complexity of autism.
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13
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Thompson L, Gillberg C, Landberg S, Kantzer AK, Miniscalco C, Barnevik Olsson M, Eriksson MA, Fernell E. Autism With and Without Regression: A Two-Year Prospective Longitudinal Study in Two Population-Derived Swedish Cohorts. J Autism Dev Disord 2019; 49:2281-2290. [PMID: 30734177 PMCID: PMC6546868 DOI: 10.1007/s10803-018-03871-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Two community-based cohorts of children with autism spectrum disorder, examined using similar assessment protocols, were pooled (n = 301) and subdivided according to history of regression. Those with regression (n = 62), 20.5% of the combined cohort, were contrasted with those without regression (n = 241) at first assessment (age range 19–60 months) and at 2-year follow-up on a range of measures. The regression group was significantly more functionally impaired, with regard to intellectual function (p < .001), language development (p < .001), and to severity of autism (p < .01) at both T1 and T2. Only 14 (23.3%) had a clearly identified underlying etiology [24 (18.6%) in the non-regressive group]. There were no significant differences between those who had regressed ‘from normal’ and those who had regressed ‘from low’ functioning.
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Affiliation(s)
- Lucy Thompson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden. .,Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Sara Landberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Anne-Katrin Kantzer
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Carmela Miniscalco
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Martina Barnevik Olsson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,PRIMA Child and Adult Psychiatry, Stockholm, Sweden
| | - Mats A Eriksson
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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14
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Tzang RF, Chang CH, Chang YC, Lane HY. Autism Associated With Anti-NMDAR Encephalitis: Glutamate-Related Therapy. Front Psychiatry 2019; 10:440. [PMID: 31293459 PMCID: PMC6598425 DOI: 10.3389/fpsyt.2019.00440] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/03/2019] [Indexed: 12/21/2022] Open
Abstract
The purpose of this review is to correlate autism with autoimmune dysfunction in the absence of an explanation for the etiology of autism spectrum disorder. The anti-N-methyl-D-aspartate receptor (anti-NMDAR) autoantibody is a typical synaptic protein that can bind to synaptic NMDA glutamate receptors, leading to dysfunctional glutamate neurotransmission in the brain that manifests as psychiatric symptoms (psychosis, hallucinations, and personality changes). Detection of autoantibodies, cytokines, decreased lymphocytes, serum immunoglobulin level imbalance, T-cell mediated immune profile, maternal infection history, and children's infection history can all be vital biological markers of autoimmune autism. Diagnosing autoimmune encephalitis sooner can increase the effectiveness of curative treatments-such as immune therapy or immune modulatory therapy-that may prevent the long-term consequence of being misdiagnosed with autism spectrum disorder. Glutamate therapy primarily normalizes glutamate neurotransmission and can be a new add-on intervention alongside antipsychotics for treating autoimmune autism.
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Affiliation(s)
- Ruu-Fen Tzang
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Mackay Medicine, Nursing and Management College, Taipei, Taiwan
| | - Chuan-Hsin Chang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei, Taiwan
| | - Yue-Cune Chang
- Department of Mathematics, Tamkang University, Taipei, Taiwan
| | - Hsien-Yuan Lane
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
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15
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Intravenous immunoglobulin for the treatment of autoimmune encephalopathy in children with autism. Transl Psychiatry 2018; 8:148. [PMID: 30097568 PMCID: PMC6086890 DOI: 10.1038/s41398-018-0214-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/07/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023] Open
Abstract
The identification of brain-targeted autoantibodies in children with autism spectrum disorder (ASD) raises the possibility of autoimmune encephalopathy (AIE). Intravenous immunoglobulin (IVIG) is effective for AIE and for some children with ASD. Here, we present the largest case series of children with ASD treated with IVIG. Through an ASD clinic, we screened 82 children for AIE, 80 of them with ASD. IVIG was recommended for 49 (60%) with 31 (38%) receiving the treatment under our care team. The majority of parents (90%) reported some improvement with 71% reporting improvements in two or more symptoms. In a subset of patients, Aberrant Behavior Checklist (ABC) and/or Social Responsiveness Scale (SRS) were completed before and during IVIG treatment. Statistically significant improvement occurred in the SRS and ABC. The antidopamine D2L receptor antibody, the anti-tubulin antibody and the ratio of the antidopamine D2L to D1 receptor antibodies were related to changes in the ABC. The Cunningham Panel predicted SRS, ABC, parent-based treatment responses with good accuracy. Adverse effects were common (62%) but mostly limited to the infusion period. Only two (6%) patients discontinued IVIG because of adverse effects. Overall, our open-label case series provides support for the possibility that some children with ASD may benefit from IVIG. Given that adverse effects are not uncommon, IVIG treatment needs to be considered cautiously. We identified immune biomarkers in select IVIG responders but larger cohorts are needed to study immune biomarkers in more detail. Our small open-label exploratory trial provides evidence supporting a neuroimmune subgroup in patients with ASD.
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16
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Melamed IR, Heffron M, Testori A, Lipe K. A pilot study of high-dose intravenous immunoglobulin 5% for autism: Impact on autism spectrum and markers of neuroinflammation. Autism Res 2018; 11:421-433. [PMID: 29427532 DOI: 10.1002/aur.1906] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 11/07/2017] [Accepted: 11/25/2017] [Indexed: 12/12/2022]
Abstract
Research has shown that a subset of the autism spectrum disorder (ASD) population presents with immune dysregulation. To explore this topic further, we investigated the efficacy and tolerability of intravenous immunoglobulin (IVIG) infusion in children with ASD. In this study, participants were recruited based on a diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified. Participants also showed evidence of immune dysfunction based on abnormal levels of specific biomarkers, including CD40 ligand (CD154), lymphocyte stimulation, and T or B cell dysfunction. Of 17 screened patients, 14 completed the trial and received IVIG treatment (1 g/kg dose) for ten 21-day treatment cycles. The primary endpoint was disease improvement assessed using standardized cognitive and behavioral tests (Children's Communication Checklist [CCC-2], Social Responsiveness Scale [SRS], Aberrant Behavior Checklist [ABC], Clinical Global Impressions-Severity [CGI-S] and -Improvement [CGI-I], Autism Diagnostic Observation Schedule [ADOS], and Peabody Picture Vocabulary Test [PPVT]). Secondary endpoints included experimental biomarkers such as CD154, toll-like receptor-4, memory B cells, FOXP3, and lymphocyte stimulation. Significant improvements from baseline to study endpoint were observed in several subscales of the CCC-2, SRS, CGI-I, CGI-S, and ADOS, including Associated Maladaptive Behaviors (P ≤ .043), Reciprocal Social Interaction (P = .015), Communication (P < .001), and Stereotyped Behaviors and Repetitive Interests (P ≤ .013). Statistically significant reductions were also seen in numerous secondary outcomes of immunological biomarkers indicative of neuroinflammation. IVIG was well tolerated; no subjects withdrew due to an adverse event, and clinical data showed no evidence of thromboembolic events. Autism Res 2018, 11: 421-433. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY Since research has demonstrated a link between autism spectrum disorder (ASD) and immune dysfunction, this study investigated the efficacy and tolerability of intravenous immunoglobulin (IVIG) infusion in children with ASD. Fourteen patients received IVIG treatment and were assessed using standardized cognitive and behavioral tests. Following treatment with IVIG, significant improvement was observed across several subscales of the clinical tests and significant reductions were seen in the markers of neuroinflammation. These data suggest that inflammatory etiologies may play a role in select cases of autism, and IVIG treatment may exert a positive impact on behaviors and markers of inflammation in ASD.
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Affiliation(s)
| | | | | | - Kellie Lipe
- IMMUNOe Research Centers, Centennial, Colorado
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17
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Scott O, Shi D, Andriashek D, Clark B, Goez HR. Clinical clues for autoimmunity and neuroinflammation in patients with autistic regression. Dev Med Child Neurol 2017; 59:947-951. [PMID: 28383115 DOI: 10.1111/dmcn.13432] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 12/20/2022]
Abstract
AIM Autistic regression is a unique variant within the autism spectrum disorders (ASDs), with recent reports raising the possibility of immune aetiology. This study explores clinical clues for an association between autistic regression and autoimmunity. METHOD Single-centre charts of children diagnosed with ASD in 2014 were reviewed. We compared the rates of: (1) familial autoimmunity in first-degree and second-degree relatives; (2) febrile illness preceding initial parental concern, as a potential precipitant of immune activation; and (3) possible non-immune precipitants such as pregnancy and postnatal complications. RESULTS The charts of 206 children with ASD and 33 diagnosed with autistic regression variant were reviewed. The incidence of febrile illness in the 6 months prior to initial parental concern was significantly higher in the children with autistic regression compared with those with ASD (30% vs 0%; p<0.001). The overall prevalence of familial autoimmunity was also higher in children with autistic regression compared with those with ASD (33% vs 12%; p<0.001). Type 1 diabetes and autoimmune thyroiditis were both more common in families with children with autistic regression. Other non-immune risk factors did not differ between the two groups. INTERPRETATION Our findings suggest that predisposition to autoimmunity, and immune/inflammatory activation, may be associated with autistic regression.
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Affiliation(s)
- Ori Scott
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Diya Shi
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Diana Andriashek
- Department of Pediatrics, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Brenda Clark
- Department of Pediatrics, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Helly R Goez
- Division of Pediatric Neurology, University of Alberta, Edmonton, AB, Canada
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18
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Remy KE, Custer JW, Cappell J, Foster CB, Garber NA, Walker LK, Simon L, Bagdure D. Pediatric Anti- N-Methyl-d-Aspartate Receptor Encephalitis: A Review with Pooled Analysis and Critical Care Emphasis. Front Pediatr 2017; 5:250. [PMID: 29226117 PMCID: PMC5705558 DOI: 10.3389/fped.2017.00250] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 11/06/2017] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is being recognized with increasing frequency among children. Given the paucity of evidence to guide the critical care management of these complex patients, we provide a comprehensive review of the literature with pooled analysis of published case reports and case series. METHODS We performed a comprehensive literature search using PubMed, Scopus, EMBASE, and Web of Science for relevant published studies. The literature search was conducted using the terms NMDA, anti-NMDA, Anti-N-methyl-d-aspartate, pediatric encephalitis, and anti-NMDAR and included articles published between 2005 and May 1, 2016. RESULTS Forty-eight references met inclusion criteria accounting for 373 cases. For first-line treatments, 335 (89.8%) received high-dose corticosteroids, 296 received intravenous immunoglobulin (79.3%), and 116 (31%) received therapeutic plasma exchange. In these, 187 children (50.1%) had a full recovery with only minor deficits, 174 patients (46.7%) had partial recovery with major deficits, and 12 children died. In addition, 14 patients were reported to require mechanical ventilation. CONCLUSION Anti-NMDA encephalitis is a formidable disease with great variation in clinical presentation and response to treatment. With early recognition of this second most common cause of pediatric encephalitis, a multidisciplinary approach by physicians may provide earlier access to first- and second-line therapies. Future studies are needed to examine the efficacy of these current therapeutic strategies on long-term morbidity.
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Affiliation(s)
- Kenneth E Remy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States.,Critical Care Medicine Department, Clinical Center, The National Institutes of Health, Bethesda, MD, United States.,Division of Pediatric Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Jason W Custer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joshua Cappell
- Divisions of Pediatric Neurology and Critical Care, Departments of Neurology and Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Cortney B Foster
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nan A Garber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - L Kyle Walker
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Liliana Simon
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Dayanand Bagdure
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
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19
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Hacohen Y, Wright S, Gadian J, Vincent A, Lim M, Wassmer E, Lin JP. N-methyl-d-aspartate (NMDA) receptor antibodies encephalitis mimicking an autistic regression. Dev Med Child Neurol 2016; 58:1092-4. [PMID: 27255282 DOI: 10.1111/dmcn.13169] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 12/23/2022]
Abstract
Expressive dysphasia and mutism are common clinical features in children and adults with N-methyl-d-aspartate receptor antibodies (NMDAR-Ab) encephalitis, and are likely to result from NMDAR hypofunction. A prodromal loss of social and communication skills can typify that of an autistic regression, particularly when presenting under the age of 3 years. Here we describe two toddlers who presented with developmental regression, particularly of their social communication skills, mimicking an autistic regression, who were found to have NMDAR-Ab in the serum and cerebrospinal fluid. Although both patients had some other neurological features, they were subtle, which resulted in delayed diagnosis of NMDAR-Ab encephalitis. Importantly, immunotherapy was beneficial in both patients, with significant improvement of their language skills and behaviour.
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Affiliation(s)
- Yael Hacohen
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Sukhvir Wright
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jonathan Gadian
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ming Lim
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Jean-Pierre Lin
- Paediatric Neuroscience, Evelina Children's Hospital @ Guys and St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, London, UK
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20
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Brenton JN, Kim J, Schwartz RH. Approach to the Management of Pediatric-Onset Anti-N-Methyl-d-Aspartate (Anti-NMDA) Receptor Encephalitis: A Case Series. J Child Neurol 2016; 31:1150-5. [PMID: 27121044 DOI: 10.1177/0883073816643406] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 03/07/2016] [Indexed: 11/15/2022]
Abstract
Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is a treatable cause of autoimmune encephalitis. It remains unclear if the natural history of this disease is altered by choice of acute therapy or the employment of chronic immunotherapy. Chart review was undertaken for pediatric patients diagnosed with anti-NMDA receptor encephalitis. Data obtained included patient demographics, disease manifestations, treatment course, and clinical outcomes. Ten patients with anti-NMDA receptor encephalitis were identified. All patients were treated with immunotherapy in the acute period, and all patients experienced good recovery. Neurologic relapse did not occur in any patient. All patients received varied forms of chronic immunosuppression to prevent relapses. Complications of chronic immunotherapy occurred in 50% of patients. The benefits of chronic immunotherapy and the duration of use should be carefully weighed against the risks. Complications from immunotherapy are not uncommon and can be serious. Clinical trials assessing the benefit of long-term immunotherapy in this population are needed.
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Affiliation(s)
- J Nicholas Brenton
- Department of Neurology, Division of Pediatric Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Richard H Schwartz
- Department of Pediatrics, Inova Children's Hospital, Falls Church, VA, USA
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21
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Brenton JN, Goodkin HP. Antibody-Mediated Autoimmune Encephalitis in Childhood. Pediatr Neurol 2016; 60:13-23. [PMID: 27343023 DOI: 10.1016/j.pediatrneurol.2016.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The differential diagnosis of encephalitis in childhood is vast, and evaluation for an etiology is often unrevealing. Encephalitis by way of autoimmunity has long been suspected, as in cases of acute disseminated encephalomyelitis; however, researchers have only recently reported evidence of antibody-mediated immune dysregulation resulting in clinical encephalitis. MAIN FINDINGS These pathologic autoantibodies, aimed at specific neuronal targets, can result in a broad spectrum of symptoms including psychosis, catatonia, behavioral changes, memory loss, autonomic dysregulation, seizures, and abnormal movements. Autoimmune encephalitis in childhood is often quite different from adult-onset autoimmune encephalitis in clinical presentation, frequency of tumor association, and ultimate prognosis. As many of the autoimmune encephalitides are sensitive to immunotherapy, prompt diagnosis and initiation of appropriate treatment are paramount. CONCLUSIONS Here we review the currently recognized antibody-mediated encephalitides of childhood and will provide a framework for diagnosis and treatment considerations.
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Affiliation(s)
- J Nicholas Brenton
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia.
| | - Howard P Goodkin
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, Charlottesville, Virginia
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22
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Fischer CE, Golas AC, Schweizer TA, Munoz DG, Ismail Z, Qian W, Tang-Wai DF, Rotstein DL, Day GS. Anti N-methyl-D-aspartate receptor encephalitis: a game-changer? Expert Rev Neurother 2016; 16:849-59. [PMID: 27123777 DOI: 10.1080/14737175.2016.1184088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an inflammatory disorder of the brain that has garnered significant interest within the medical and lay communities. There is a need for formal guidelines to assist physicians in identifying patients who should undergo testing for NMDAR encephalitis, recognizing the high potential for this potentially treatable disease to mimic more common disorders, and consequently remain undiagnosed. AREAS COVERED This review highlights the impact of the discovery of NMDAR encephalitis on the fields of neurology and psychiatry, and discusses the steps that are necessary to improve recognition and treatment of NMDAR encephalitis. Expert commentary: While much progress has been made in our understanding of NMDAR encephalitis, much work remains to be done to delineate the underlying disease mechanisms and their relevance to brain function.
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Affiliation(s)
- Corinne E Fischer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,c Faculty of Medicine, Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Angela C Golas
- d Department of Psychiatry , University of Toronto, Geriatric Psychiatry Subspecialty , Toronto , ON , Canada
| | - Tom A Schweizer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,e Institute of Biomaterials and Biomedical Engineering , University of Toronto , Toronto , ON , Canada.,f Division of Neurosurgery, Department of Surgery, Faculty of Medicine , University of Toronto , Toronto , ON , Canada.,g Division of Neurosurgery , St. Michael's Hospital , Toronto , ON , Canada
| | - David G Munoz
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,h Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , ON , Canada.,i Division of Pathology, Department of Laboratory Medicine and Pathobiology , St. Michael's Hospital , Toronto , ON , Canada
| | - Zahinoor Ismail
- j Hotchkiss Brain Institute , University of Calgary , Calgary , AB , Canada
| | - Winnie Qian
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada
| | - David F Tang-Wai
- k Department of Medicine (Neurology and Geriatric Medicine) , University of Toronto , Toronto , ON , Canada.,l UHN Memory Clinic , Toronto Western Hospital , Toronto , ON , Canada
| | - Dalia L Rotstein
- m Department of Medicine (Neurology) , University of Toronto, St. Michael's Hospital , Toronto , ON , Canada
| | - Gregory S Day
- n Knight Alzheimer Disease Research Center, Department of Neurology , Washington University in St. Louis , St. Louis , MO , Canada
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23
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Kern JK, Geier DA, Sykes LK, Geier MR. Relevance of Neuroinflammation and Encephalitis in Autism. Front Cell Neurosci 2016; 9:519. [PMID: 26834565 PMCID: PMC4717322 DOI: 10.3389/fncel.2015.00519] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 12/24/2015] [Indexed: 12/12/2022] Open
Abstract
In recent years, many studies indicate that children with an autism spectrum disorder (ASD) diagnosis have brain pathology suggestive of ongoing neuroinflammation or encephalitis in different regions of their brains. Evidence of neuroinflammation or encephalitis in ASD includes: microglial and astrocytic activation, a unique and elevated proinflammatory profile of cytokines, and aberrant expression of nuclear factor kappa-light-chain-enhancer of activated B cells. A conservative estimate based on the research suggests that at least 69% of individuals with an ASD diagnosis have microglial activation or neuroinflammation. Encephalitis, which is defined as inflammation of the brain, is medical diagnosis code G04.90 in the International Classification of Disease, 10th revision; however, children with an ASD diagnosis are not generally assessed for a possible medical diagnosis of encephalitis. This is unfortunate because if a child with ASD has neuroinflammation, then treating the underlying brain inflammation could lead to improved outcomes. The purpose of this review of the literature is to examine the evidence of neuroinflammation/encephalitis in those with an ASD diagnosis and to address how a medical diagnosis of encephalitis, when appropriate, could benefit these children by driving more immediate and targeted treatments.
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Affiliation(s)
- Janet K. Kern
- Institute of Chronic Illnesses, Inc., Silver SpringMD, USA
| | - David A. Geier
- Institute of Chronic Illnesses, Inc., Silver SpringMD, USA
| | | | - Mark R. Geier
- Institute of Chronic Illnesses, Inc., Silver SpringMD, USA
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Abstract
The immune system's role in the pathophysiology of several neuropsychiatric disorders has been the subject of research for many decades. Despite suggestive evidence from genetic, epidemiologic, and immunologic studies, those findings did not translate into clinical practice. Recent recognition of antibody-mediated central nervous system (CNS) disorders has fueled the search for a subgroup of patients with an antibody-mediated psychiatric illness. This chapter focuses on the current understanding of autoimmune CNS disorders and how they may be relevant to psychiatric disorders, particularly schizophrenia and autism. We review the results provided by antibody screening in psychiatric patient groups and discuss future directions to establish whether those findings will be meaningful in clinical practice.
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Affiliation(s)
- Ester Coutinho
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Kim SY, Choi SA, Ryu HW, Kim H, Lim BC, Hwang H, Chae JH, Choi J, Kim KJ, Hwang YS, Lee ST, Chu K, Lee SK. Screening Autoimmune Anti-neuronal Antibodies in Pediatric Patients with Suspected Autoimmune Encephalitis. J Epilepsy Res 2014; 4:55-61. [PMID: 25625089 PMCID: PMC4295054 DOI: 10.14581/jer.14012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/01/2014] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: The aim of this study was to identify and describe the pediatric autoimmune encephalitis cases positive for anti-neuronal antibody tests. Methods: Screening of six anti-neuronal antibodies in 23 children with suspected autoimmune encephalitis was performed by cell-based indirect immunofluorescence test with patients’ serum or cerebrospinal fluid. Results: Among the 23 cases enrolled here, eight patients (35%) were positive for the anti-N-methyl-d-aspartate (NMDA) receptor antibody and one patient (4%) was positive for the anti-contactin-associated protein-like 2 (CASPR2) antibody. In the anti-NMDA receptor antibody-positive group, seizure and movement disorders were the most prominent features and were present in all patients. A tumor was present in only one patient. Three patients with infant- and toddler-onset disease did not exhibit a classic multistage illness. In addition to seizure and dyskinesia, aphasia or mutism without severe consciousness impairment was present in all three patients. These atypical clinical presentations may suggest different pathomechanism of anti-NMDA receptor encephalitis among these age groups. The patient who was positive for the anti-CASPR2 antibody was an 8-year-old girl who presented with fever, encephalopathy, and seizure. Neuromyotonia or other dyskinesia was not present. Conclusions: Eight anti-NMDA receptor antibody positive patients and one CASPR2 positive patient were identified from the screening of six anti-neuronal antibodies in pediatric patients suspected with autoimmune encephalitis. Developmental regression specifically for language skills was suggested as one of the atypical clinical features in infants and toddler onset anti-NMDA receptor antibody positive patients.
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Affiliation(s)
- Soo Yeon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Sun Ah Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Hye Won Ryu
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Hunmin Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Hee Hwang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Jong-Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Jieun Choi
- Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Yong Seung Hwang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul; ; Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul
| | - Soon-Tae 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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Milenkovic M, Mielnik CA, Ramsey AJ. NMDA receptor-deficient mice display sexual dimorphism in the onset and severity of behavioural abnormalities. GENES BRAIN AND BEHAVIOR 2014; 13:850-62. [PMID: 25327402 DOI: 10.1111/gbb.12183] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 10/01/2014] [Accepted: 10/16/2014] [Indexed: 01/14/2023]
Abstract
N-methyl-d-aspartate (NMDA) receptor-deficient mice can be used to understand the role that NMDA receptors (NMDARs) play in the pathophysiology of neurodevelopmental disorders such as schizophrenia. Genetically modified mice with low levels of NR1 subunit (NR1 knockdown mice) have reduced receptor levels throughout development, and have robust abnormalities in behaviours that are relevant to schizophrenia. We traced the onset and severity of these behaviours at three developmental stages to understand when in development the underlying circuits depend on intact NMDAR function. We examined social behaviour, working memory, executive function, locomotor activity and stereotypy at 3, 6 and 12 weeks of age in NR1 knockdown mice and their wild-type littermates. We discovered that each of these behaviours had a unique developmental trajectory in mutant mice, and males showed an earlier onset and severity than females in several behaviours. Hyperlocomotion was most substantial in juvenile mice and plateaued in adult mice, whereas stereotypy progressively worsened with age. Impairments in working memory and sociability were sexually dimorphic, with deficits first detected in peri-adolescent males but only detected in adult females. Interestingly, executive function was most impaired in peri-adolescent mice of either sex. Furthermore, while juvenile mutant mice had some ability to problem solve in the puzzle box test, the same mice lost this ability when tested 4 weeks later. Our studies highlight key developmental periods for males and females in the expression of behaviours that are relevant to psychiatric disorders.
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Affiliation(s)
- M Milenkovic
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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Abstract
Over the past 10 years, the continual discovery of novel forms of encephalitis associated with antibodies to cell-surface or synaptic proteins has changed the paradigms for diagnosing and treating disorders that were previously unknown or mischaracterized. We review here the process of discovery, the symptoms, and the target antigens of 11 autoimmune encephalitic disorders, grouped by syndromes and approached from a clinical perspective. Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis, several subtypes of limbic encephalitis, stiff-person spectrum disorders, and other autoimmune encephalitides that result in psychosis, seizures, or abnormal movements are described in detail. We include a novel encephalopathy with prominent sleep dysfunction that provides an intriguing link between chronic neurodegeneration and cell-surface autoimmunity (IgLON5). Some of the caveats of limited serum testing are outlined. In addition, we review the underlying cellular and synaptic mechanisms that for some disorders confirm the antibody pathogenicity. The multidisciplinary impact of autoimmune encephalitis has been expanded recently by the discovery that herpes simplex encephalitis is a robust trigger of synaptic autoimmunity, and that some patients may develop overlapping syndromes, including anti-NMDAR encephalitis and neuromyelitis optica or other demyelinating diseases.
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Affiliation(s)
- Frank Leypoldt
- Service of Neurology, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain; Institute of Clinical Chemistry, Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
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Pollak TA, Nicholson TR, Mellers JDC, Vincent A, David AS. Epilepsy-related psychosis: a role for autoimmunity? Epilepsy Behav 2014; 36:33-8. [PMID: 24840753 DOI: 10.1016/j.yebeh.2014.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/22/2014] [Accepted: 04/23/2014] [Indexed: 12/20/2022]
Abstract
Postictal psychosis (PIP) is a serious psychiatric complication of epilepsy that occurs in approximately 6% of patients following multiple complex partial or generalized seizures. The psychosis is classically described as having a pleomorphic phenomenology, including paranoid, grandiose, and religious delusions as well as multimodal hallucinations with prominent affective changes and agitation. Little is understood about the pathophysiology of the condition. There has been a recent increase in interest in the relevance of autoimmunity to the pathogenesis of both epilepsy and psychosis. Studies have demonstrated the presence of antibodies directed against synaptic autoantigens (such as the N-methyl-d-aspartate receptor or the voltage-gated potassium channel complex) in approximately 10% of cases of sporadic epilepsy. These same autoantibodies are known to cause encephalopathy syndromes which feature psychiatric symptoms, usually psychosis, as a prominent part of the phenotype as well as other neurological features such as seizures, movement disorders, and autonomic dysfunction. It is beginning to be asked if these antibodies can be associated with a purely psychiatric phenotype. Here, we hypothesize that PIP may be an autoimmune phenomenon mediated by autoantibodies against synaptic antigens. More specifically, we outline a potential mechanism whereby long or repeated seizures cause short-lived blood-brain barrier (BBB) dysfunction during which the brain becomes exposed to pathogenic autoantibodies. In essence, we propose that PIP is a time-limited, seizure-dependent, autoantibody-mediated encephalopathy syndrome. We highlight a number of features of PIP that may be explained by this mechanism, such as the lucid interval between seizures and onset of psychosis and the progression in some cases to a chronic, interictal psychosis.
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Affiliation(s)
- T A Pollak
- National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London, UK; Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
| | - T R Nicholson
- National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London, UK; Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
| | | | - A Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - A S David
- Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
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