Anti-N-methyl-D-aspartate receptor encephalitis concomitant with multifocal subcortical white matter lesions on magnetic resonance imaging: a case report and review of the literature

Autoimmune encephalitis : Part 1 (Epidemiology, Pathophysiology and Clinical spectrum)

Since the identification of anti-N-methyl-D-aspartate (NMDA) receptor antibodies about 15 years ago, many patients with rapidly progressing psychiatric symptoms, abnormal movements, seizures or unexplained coma, have been diagnosed with autoimmune encephalitis (AE). The symptom onset is often unspecific and might mimic psychiatric disease, but the later course is frequently characterized by severe disease, often requiring intensive care. Clinical and immunological criteria are helpful in identifying the patients, but no biomarkers exist to guide the clinician in therapy or predict outcome. While persons of all ages can be affected by AE, some types of AE affect more children and young adults and are more prevalent in women. This review will focus on encephalitides associated with neuronal cell-surface or synaptic antibodies, which can result in characteristic syndromes, and are often recognizable on clinical grounds. AE subtypes associated with antibodies against extracellular epitopes can occur with or without tumours. Because the antibodies bind and alter the function of the antigen, the effects are often reversible if immunotherapy is initiated, and the prognosis is favourable in most instances. The first part of this series will introduce the topic, provide an overview of current neuronal surface antibodies and how they present, describe the most common subtype, anti-NMDA receptor encephalitis, and discuss the difficulties in recognizing patients with underlying AE amongst patients with new onset psychiatric disorders.

Diffusion kurtosis imaging and diffusion tensor imaging parameters applied to white matter and gray matter of patients with anti-N-methyl-D-aspartate receptor encephalitis

Objectives

To compare parameters of diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) to evaluate which can better describe the microstructural changes of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients and to characterize the non-Gaussian diffusion patterns of the whole brain and their correlation with neuropsychological impairments in these patients.

Materials and methods

DTI and DKI parameters were measured in 57 patients with anti-NMDAR encephalitis and 42 healthy controls. Voxel-based analysis was used to evaluate group differences between white matter and gray matter separately. The modified Rankin Scale (mRS) was used to evaluate the severity of the neurofunctional recovery of patients, the Montreal Cognitive Assessment (MoCA) was used to assess global cognitive performance, and the Hamilton Depression Scale (HAMD) and fatigue severity scale (FSS) were used to evaluate depressive and fatigue states.

Results

Patients with anti-NMDAR encephalitis showed significantly decreased radial kurtosis (RK) in the right extranucleus in white matter (P < 0.001) and notably decreased kurtosis fractional anisotropy (KFA) in the right precuneus, the right superior parietal gyrus (SPG), the left precuneus, left middle occipital gyrus, and left superior occipital gyrus in gray matter (P < 0.001). Gray matter regions with decreased KFA overlapped with those with decreased RK in the left middle temporal gyrus, superior temporal gyrus (STG), supramarginal gyrus (SMG), postcentral gyrus (POCG), inferior parietal but supramarginal gyrus, angular gyrus (IPL) and angular gyrus (ANG) (P < 0.001). The KFA and RK in the left ANG, IPL and POCG correlated positively with MoCA scores. KFA and RK in the left ANG, IPL, POCG and SMG correlated negatively with mRS scores. KFA in the left precuneus and right SPG as well as RK in the left STG correlated negatively with mRS scores. No significant correlation between KFA and RK in the abnormal brain regions and HAMD and FSS scores was found.

Conclusion

The microstructural changes in gray matter were much more extensive than those in white matter in patients with anti-NMDAR encephalitis. The brain damage reflected by DKI parameters, which have higher sensitivity than parameters of DTI, correlated with cognitive impairment and the severity of the neurofunctional recovery.

CSF Findings in Acute NMDAR and LGI1 Antibody-Associated Autoimmune Encephalitis

Background and Objectives

CSF in antibody-defined autoimmune encephalitis (AE) subtypes shows subtype-dependent degrees of inflammation ranging from rare and often mild to frequent and often robust. AEs with NMDA receptor antibodies (NMDAR-E) and leucine-rich glioma-inactivated protein 1 antibodies (LGI1-E) represent opposite ends of this spectrum: NMDAR-E with typically frequent/robust and LGI1-E with rare/mild CSF inflammation. For a more in-depth analysis, we characterized CSF findings in acute, therapy-naive NMDAR-E and LGI1-E in a multicentric, retrospective, cross-sectional setting.

Methods

Eighty-two patients with NMDAR-E and 36 patients with LGI1-E from the GErman NEtwork for Research of AuToimmune Encephalitis (GENERATE) with lumbar puncture within 90 days of onset and before immunotherapy were included. CSF parameters comprised leukocytes, oligoclonal bands (OCBs), and CSF/serum ratios for albumin, immunoglobulin G (IgG), A (IgA), and M (IgM), the latter 3 converted to Z scores according to Reiber formulas. The MRZ reaction was tested in 14 patients with NMDAR-E and 6 patients with LGI1-E, respectively.

Results

CSF was abnormal in 94% of NMDAR-E but only in 36% of LGI1-E patients. Robust quantitative intrathecal immunoglobulin synthesis (IIS, IgG > IgM >> IgA) was characteristic for NMDAR-E, but absent in LGI-E. In NMDAR-E, CSF leukocytes were higher when IIS was present or more pronounced. In addition, in NMDAR-E, CSF leukocytes were lower and IIS occurred less often and if so to a lesser degree at older age. Patients with NMDAR-E with severe functional impairment more often had positive OCBs. In CSF obtained later than 3 weeks of onset, leukocytes were lower. In parallel, the correlation of leukocytes with IIS disappeared as IIS was partially independent of disease duration. The MRZ reaction was positive in 5 (36%) patients with NMDAR-E. All these associations were completely absent in LGI1-E. Here, younger patients showed more blood-CSF barrier dysfunction. In LGI1-E, but not in NMDAR-E, the blood-CSF barrier was more dysfunctional when CSF leukocytes were higher.

Discussion

NMDAR-E and LGI-E differ in their typical extent of CSF inflammation. In addition, the patterns formed by the different inflammatory CSF parameters and their relationship with disease severity, age, and disease duration are subtype-characteristic. Moreover, signs for multiple sclerosis-like chronic inflammation are present in a subgroup of patients with NMDAR-E. These CSF patterns might be markers for the different immunopathogeneses of LGI1-E and NMDAR-E.

Analysis of the Effect of Incentive Nursing Intervention in Children with Severe Viral Encephalitis and Myocarditis during Rehabilitation Based on Diffusion Weighted MRI

Background

Severe viral encephalitis in children causes a viral infection that damages their central nervous system. This situation arises the mental abnormalities, sudden rise in body temperature, disturbance of consciousness, and so forth in children, which can be life-threatening.

Objective

This work aimed at exploring the effect of diffusion weighted MRI on children with severe viral encephalitis and myocarditis.

Methods

This work presents a diffusion weighted MRI scanning method that involves scanning through a serial imaging device, axial scanning, and sagittal and coronal scanning. 60 children with severe viral encephalitis and myocarditis who admitted to Brain Hospital of Hunan Province from April 2017 to May 2020 were deemed as research subjects. All the children underwent CT and MRI examination, blood routine examination, and cerebrospinal fluid examination after admission. This work uses the random number table method to classify the subjects into control group and observation group, each consisting of 30 cases. Children in the control group were provided with the routine nursing intervention, whereas children in the observation group were subjected to incentive nursing intervention. The baseline data, ECG monitoring indicators, body abnormalities, and clinical symptom relief time of the two groups of children were compared and the results of diffusion weighted MRI scans were analyzed and the ADC values were counted.

Results

The two groups of children were compared on the basis of baseline data, and the variation was not statistically substantial (P > 0.05). The cases of children in the control group had higher heart rate and respiration, and physical dysfunction, language dysfunction, unconsciousness, and nervous dysfunction were more than those in the observation group. However, the cases of blood oxygen saturation were less than those of the observation group. After nursing intervention done for the control group, remission time of clinical symptoms such as convulsion, physical dysfunction, unconsciousness, and nerve dysfunction was longer relative to the observation group (all P < 0.05 are considered).

Conclusion

The diffusion weighted MRI had diagnostic significance for severe viral encephalitis and myocarditis. For children with severe viral encephalitis and myocarditis, clinical incentive nursing intervention was particularly imperative. It can not only help children to relieve symptoms and control the deterioration of the disease in a short time but also help improve the quality of life of the children and the confidence of family members to cope with the disease.

Catatonia in N-methyl-d-aspartate receptor antibody encephalitis: Phenomenological characteristics from a systematic review of case reports

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.

Nursing care in anti-N-methyl-D-aspartate receptor encephalitis: A case series

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a paraneoplastic limbic encephalitis, recently identified.To summarize our experience in the nursing care of patients with anti-NMDAR encephalitis managed with surgery and pharmacotherapy.This study included 45 patients treated between July 2015 and November 2016. Laparoscopic oophorocystectomy was performed in 11 female patients with teratomas. Eleven patients required tracheal intubation or tracheotomy and ventilation.The patients were hospitalized for an average of 25.2 days. The mental and neurological symptoms were significantly relieved 23.6 ± 4.8 days after surgery or immunotherapy. Near-normal function was restored in 11 patients, while 34 patients had varying degrees of dysfunction at discharge. After follow-up of 1 to 18 months, 24 patients were found to have permanent impairments.Appropriate symptomatic nursing care is required to ensure the safety of patients with anti-NMDAR encephalitis.

Phylogenetic Analysis to Explore the Association Between Anti-NMDA Receptor Encephalitis and Tumors Based on microRNA Biomarkers

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.

The diffuse involvement of anti-N-methyl-D-aspartate receptor encephalitis in brain: a case report

Background

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe and most common autoimmune encephalitis in patients under 40 years old. Anti-NMDAR encephalitis has various clinical and neuroimaging findings. Here we report a special case of an anti-NMDAR encephalitis who had diffuse lesions in bilateral hemispheres with mild mass effects in left basal ganglia area.

Case presentations

A 28-year-old female anti-NMDAR encephalitis patient mainly presented with headache and fever. Brain magnetic resonance image (MRI) showed slightly contrasted diffuse lesions, involving the left temporal and frontal lobes, left basal ganglia area and splenium of corpus callosum, as well as the right frontal lobe, with mild edema surrounded in the left basal ganglia area. Cerebrospinal fluid (CSF) revealed a moderate pleocytosis with normal protein and glucose levels. Anti-NMDAR antibodies were identified in CSF. Transvaginal ovarian ultrasound did not reveal an ovarian teratoma. The patient was treated with immunoglobulin and steroid, and had a good recovery.

Conclusions

Anti-NMDAR encephalitis has no special clinical manifestations and brain MRI is highly variable, which could be unremarkable or abnormal involving white and grey matters. The extensive lesions in frontal and temporal lobes, and basal ganglia area, with mild mass effects, have not been described previously. Recognition of various changes in brain MRI will enable the early detection of anti-NMDAR antibody and then effective treatments.

Electronic supplementary material

Supplementary information accompanies this papaer at 10.1186/s12883-019-1456-6.

Application of Plasma Exchange in Steroid-Responsive Encephalopathy

Plasma exchange has been widely used in autoimmune neurological diseases and is the standard treatment for myasthenia gravis crisis and Guillain-Barre syndrome. A growing body of research suggests that, in the clinical application of steroid-responsive encephalopathy, such as for Hashimoto's encephalopathy, limbic encephalitis, systemic lupus erythematosus encephalopathy, ANCA-associated vasculitis encephalopathy, and acute disseminated encephalomyelitis, plasma exchange is a safe, and effective option when steroids or other immunosuppressive therapies are ineffective in the short term or when contraindications are present. Additionally, plasma exchange can also be used alone or in combination with steroids, immunoglobulins, or other immunosuppressive agents to treat steroid-responsive encephalopathy. This paper reviews the clinical application of plasma exchange in steroid-responsive encephalopathy, including its indications, onset time, course, curative effects, and side effects.

Small-Cell Lung Cancer with Positive Anti-NMDAR and Anti-AMPAR Antibodies Paraneoplastic Limbic Encephalitis

We report the case of a 66-year-old woman, with paraneoplastic limbic encephalitis, treated 6 months earlier for bladder neoplasia. The patient presented to the emergency room with rapidly increasing symptoms, noninfectious cerebral spinal fluid associated with positive anti-NMDAR (as well as in serum) and positive AMPAR antibodies in the serum. Four months later, the patient was diagnosed with a small-cell lung cancer for which chemotherapy and radiotherapy was commenced. Simultaneously, endoscopic surgical treatment was undertaken for an in situ relapse of the bladder neoplasm. After the completion of 3 cycles of chemotherapy her neurological status temporarily worsened. The cerebral MRI did not show signs of encephalitis such as increased T2/FLAIR signal intensity in the mesial temporal lobes and limbic systems. No specific treatment was prescribed. Limbic encephalitis can be associated with malignant tumors such as lung carcinoma. Several cases reported in the literature have shown cognitive improvement after tumoral therapy. Regarding our experience, significant progress was achieved through immuno-modulatory treatment. A transitory deterioration of the cognitive process was perceived during the chemotherapy sessions.