1
|
Zhang Z, Zhang X, Dai M, Wu Y, You Y. Case report: A case of anti-glycine receptor encephalomyelitis triggered by post-transplant or COVID-19 infection? Front Neurol 2024; 15:1356691. [PMID: 38699057 PMCID: PMC11063230 DOI: 10.3389/fneur.2024.1356691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/11/2024] [Indexed: 05/05/2024] Open
Abstract
Even though long-term immunosuppressant drugs (ISD) are employed to inhibit immune system activity, enhancing graft functionality and patient survival in solid organ transplantation (SOT), these transplants often lead to immune complications, with post-transplant autoimmune diseases of the central nervous system (CNS) being uncommon. Here, we detail the case of a 66-year-old woman who underwent a renal transplantation 8 months prior, who was admitted with subacute onset of encephalomyelitis, accompanied by headaches, paraplegia, weakness, vomiting, and abdominal pain, with a positive COVID-19 nasopharyngeal swab test 1 month before admission. MRI scans of the brain revealed multiple lesions in the white matter of the bilateral deep frontal lobe, the left temporal lobe and insula lobe. Additionally, there were multiple short segment lesions in the spinal cord and subdural hematoma at T1, T6-T7 posterior. The serum revealed a positive result for GlyR-IgG. Following the administration of corticosteroid and intravenous immunoglobulin, there was a significant improvement in the patient's symptoms within 2 weeks, and her brain MRI showed a reduction in the lesion. Despite its rarity, we believe this to be the inaugural documentation of anti-GlyR encephalomyelitis occurring during renal transplantation. A full panel of antibodies for autoimmune encephalomyelitis is the key leading to the diagnosis.
Collapse
Affiliation(s)
- Zhengxue Zhang
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Xiang Zhang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mingming Dai
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Yingying Wu
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Yong You
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
- International Center for Aging and Cancer (ICAC), Hainan Medical University, Haikou, China
- Key Laboratory of Brain Science Research & Transformation in Tropical Environment of Hainan Province, Haikou, China
| |
Collapse
|
2
|
Toshida K, Toshima T, Itoh S, Yoshiya S, Mukaino T, Fujii T, Watanabe M, Yamasaki R, Isobe N, Yoshizumi T. Caution to Poor Adherence With Immunosuppressant Medication That Causes Coma-Onset Autoimmune Encephalitis: A Case Report and Literature Review. Transplant Proc 2023; 55:1968-1971. [PMID: 37517883 DOI: 10.1016/j.transproceed.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023]
Abstract
Autoimmune encephalitis after liver transplantation (LT) is a rare disorder. This is because patients are usually in an immunosuppressed state after LT. Here, we report a rare case of autoantibody-negative autoimmune-encephalitis-induced coma after living-donor (LD) LT. A 45-year-old woman who underwent LDLT for primary biliary cholangitis (PBC) was brought to our hospital with the chief complaint of cognitive deficiency and an episode of memory loss. Physical examination, laboratory tests, and cerebrospinal fluid analysis revealed no significant findings. However, diffusion-weighted magnetic resonance imaging showed hyperintensity in the bilateral hippocampus. No autoantibodies associated with autoimmune encephalitis were detected. The diagnosis of antibody-negative autoimmune encephalitis was made on the basis of low immunosuppressive drug levels in the blood (indicative of poor adherence) and the presence of PBC as the autoimmune disease. The patient regained consciousness after intravenous methylprednisolone pulse therapy and plasma exchange. This case highlights that when examining patients with impaired consciousness after LDLT, it is important to consider autoimmune encephalitis as a potential diagnosis.
Collapse
Affiliation(s)
- Katsuya Toshida
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Yoshiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiko Mukaino
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Fujii
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mitsuru Watanabe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
3
|
Wang DZ, Li BH, Deng BL, Guo FQ, Hu SS, Yu NW, Liu J. Anti-CASPR2 encephalitis in a liver posttransplant patient receiving immune-suppression and lenvatinib: a case report and literature review. Neurol Sci 2023; 44:1069-1072. [PMID: 36547776 DOI: 10.1007/s10072-022-06560-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
It has been assumed that patients with strict immunosuppressive treatment after solid organ transplantation have only marginal risk in developing autoimmune encephalitis. We reported a woman in her late 40 s who presented with generalized convulsions and loss of consciousness. After detailed history review, neuropsychological tests, metagenomic next-generation sequencing of serum and cerebrospinal fluid (CSF), magnetic resonance imaging (MRI) brain, and electroencephalogram, she was diagnosed as anti-CASPR2 encephalitis based on the positive anti-CASPR2 auto-antibody in serum and CSF. The patient underwent liver transplantation and has taken lenvatinib for 2 months, in addition to tacrolimus, mycophenotale mofetil, and entecavir administered for half a year. This case was the first report of anti-CASPR2 encephalitis in post-organ transplantation patients. Together with the reports of other encephalitis cases in organ transplantation, it warns the possibility of developing immune-oriented encephalitis in patients undergoing immunosuppression, especially in combination with other treatments of immunomodulatory activity.
Collapse
Affiliation(s)
- Duo-Zi Wang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Bing-Hu Li
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Bin-Lu Deng
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Fu-Qiang Guo
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Shan-Shan Hu
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Neng-Wei Yu
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Jie Liu
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| |
Collapse
|
4
|
Ma YJ, Zhao L, Li JQ, Yang L, Yan YM, Li JB, Gao LH. Epstein-Barr virus infection with non-tumor-associated Anti-N-Methyl-D-Aspartate receptor encephalitis: a case report and review of literature. Neurocase 2023; 29:1-5. [PMID: 37963293 DOI: 10.1080/13554794.2023.2280276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/30/2023] [Indexed: 11/16/2023]
Abstract
To study a case of a middle-aged male with a non-tumor-associated Epstein-Barr virus (EBV) infection associated with Anti-N-methyl-D-aspartate receptor encephalitis (NMDARE), to explore the role of EBV in the pathogenesis of anti-NMDARE. The patient was diagnosed with "Anti-NMDARE, EBV infection" by using Cerebrospinal fluid (CSF) autoimmune encephalitis profile, and Metagenomics Next-Generation Sequencing (mNGS) pathogenic microbial assays, we discuss the relationship between EBV and NMDARE by reviewed literature. EBV infection may trigger and enhance anti-NMDARE, and the higher the titer of NMDAR antibody, the more severe the clinical presentation.
Collapse
Affiliation(s)
- Yan-Jun Ma
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| | - Lei Zhao
- Department of Neurology, Hulunbuir People's Hospital, Hulunbuir, Inner Mongolia, China
| | - Jie-Qiong Li
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| | - Liu Yang
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| | - Yue-Ming Yan
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| | - Jiang-Bo Li
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| | - Li-Hong Gao
- Hulunbuir Clinical Medical College, Inner Mongolia MinZu University, Hulunbuir, Inner Mongolia, China
| |
Collapse
|
5
|
Giné-Servén E, Serra-Mestres J, Martinez-Ramirez M, Boix-Quintana E, Davi-Loscos E, Guanyabens N, Casado V, Muriana D, Torres-Rivas C, Cuevas-Esteban J, Labad J. Anti-NMDA receptor encephalitis in older adults: A systematic review of case reports. Gen Hosp Psychiatry 2022; 74:71-77. [PMID: 34929551 DOI: 10.1016/j.genhosppsych.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To ascertain the clinical characteristics of anti-NMDA receptor encephalitis (NMDARE) in older patients. METHOD A systematic literature review using PubMed and Scopus of all published case reports of NMDARE was undertaken, from database inception to June 2020. From this, cases reporting on patients older than 65 years of age and whose diagnosis was confirmed by the presence of anti-NMDAR antibodies in CSF were selected. RESULTS 23 case reports fulfilling the study's criteria were found. Median age was 70.1 years (range 65-84), fourteen were female (60.9%), and mostly presented with acute behavioral and cognitive changes (95.7%). Atypical psychosis occurred in eleven patients (47.8%) with a sudden onset and fluctuating clinical pattern of delusions (39.1%), hallucinations (30.4%), and motility disturbances (34.8%) including catatonia (17.4%). Nine patients presented with seizures (39.1%). Pleocytosis in CSF (>5 WBC) was described in twelve cases (52.2%). Eleven cases (47.8%) had abnormal brain magnetic resonance imaging (MRI) scans with limbic inflammatory lesions. Thirteen patients had an abnormal EEG (56.5%). CONCLUSION NMDARE should be included in the differential diagnosis of older patients who present with new psychiatric episodes, especially when characterized by sudden onset psychotic polymorphic symptomatology, fluctuating course with marked cognitive decline, and with catatonic features.
Collapse
Affiliation(s)
- Eloi Giné-Servén
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.
| | | | - Maria Martinez-Ramirez
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Ester Boix-Quintana
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Eva Davi-Loscos
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Nicolau Guanyabens
- Department of Neurology, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Virginia Casado
- Department of Neurology, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Desiree Muriana
- Department of Neurology, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Cristina Torres-Rivas
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Jorge Cuevas-Esteban
- Department of Psychiatry, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Javier Labad
- Department of Psychiatry, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain; Centro de Investigación en Red de Salud Mental (CIBERSAM), Madrid, Spain; Translational Neuroscience Research Unit I3PT-INc-UAB, Institut de Innovació i Investigació Parc Taulí (I3PT), Institut de Neurociències, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
6
|
Zrzavy T, Endmayr V, Bauer J, Macher S, Mossaheb N, Schwaiger C, Ricken G, Winklehner M, Glatter S, Breu M, Wimmer I, Kovacs GG, Risser DU, Klupp N, Simonitsch-Klupp I, Roetzer T, Rommer P, Berger T, Gelpi E, Lassmann H, Graus F, Dalmau J, Höftberger R. Neuropathological Variability within a Spectrum of NMDAR-Encephalitis. Ann Neurol 2021; 90:725-737. [PMID: 34562035 DOI: 10.1002/ana.26223] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/12/2021] [Accepted: 09/19/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To describe the neuropathological features of N-methyl-D-aspartate receptor (NMDAR)-encephalitis in an archival autopsy cohort. METHODS We examined four autopsies from patients with NMDAR-encephalitis; two patients were untreated, three had comorbidities: small cell lung cancer, brain post-transplant lymphoproliferative disease (PTLD), and overlapping demyelination. RESULTS The two untreated patients had inflammatory infiltrates predominantly composed of perivascular and parenchymal CD3+ /CD8- T cells and CD79a+ B cells/plasma cells in basal ganglia, amygdala, and hippocampus with surrounding white matter. The hippocampi showed a significant decrease of NMDAR-immunoreactivity that correlated with disease severity. The patient with NMDAR-encephalitis and immunosuppression for kidney transplantation developed a brain monomorphic PTLD. Inflammatory changes were compatible with NMDAR-encephalitis. Additionally, plasma cells accumulated in the vicinity of the necrotic tumor along with macrophages and activated microglia that strongly expressed pro-inflammatory activation markers HLA-DR, CD68, and IL18. The fourth patient developed demyelinating lesions in the setting of a relapse 4 years after NMDAR-encephalitis. These lesions exhibited the hallmarks of classic multiple sclerosis with radially expanding lesions and remyelinated shadow plaques without complement or immunoglobulin deposition, compatible with a pattern I demyelination. INTERPRETATION The topographic distribution of inflammation in patients with NMDAR-encephalitis reflects the clinical symptoms of movement disorders, abnormal behavior, and memory dysfunction with inflammation dominantly observed in basal ganglia, amygdala, and hippocampus, and loss of NMDAR-immunoreactivity correlates with disease severity. Co-occurring pathologies influence the spatial distribution, composition, and intensity of inflammation, which may modify patients' clinical presentation and outcome. ANN NEUROL 2021;90:725-737.
Collapse
Affiliation(s)
- Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Nilufar Mossaheb
- Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Carmen Schwaiger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gerda Ricken
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sarah Glatter
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Breu
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabor G Kovacs
- Department of Laboratory Medicine and Pathobiology and Tanz Centre for Research in Neurodegenerative Disease, University of Toronto, Toronto, ON, Canada
| | - Daniele U Risser
- Center for Forensic Medicine, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Klupp
- Center for Forensic Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Roetzer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Neurological Tissue Bank of the Biobank-Hospital Clinic-IDIBAPS, Barcelona, Spain
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Francesc Graus
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep Dalmau
- Neuroimmunology Programme, Institut d'Investigacions Biomèdiques August Pi i Sunyer Hospital Clínic, University of Barcelona, Barcelona, Spain
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Spindel J, Heckroth M, Marsano L. Antibody-negative autoimmune encephalitis as a complication of long-term immune-suppression for liver transplantation. BMJ Case Rep 2020; 13:13/9/e235777. [PMID: 32933909 DOI: 10.1136/bcr-2020-235777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Autoimmune encephalitis is a rare spectrum of disease that can be a complication of chronic immunosuppression. Diagnosis often requires the presence of antineuronal antibodies, but many causative antibodies have not yet been identified. Antibody-negative autoimmune encephalitis (AbNAE) is especially difficult to diagnose and must rely largely on exclusion of other causes. In chronically immune-suppressed transplant recipients, the differential is broad, likely resulting in underdiagnosis and worse outcomes. Here, we present a 58-year-old liver transplant recipient taking tacrolimus for prevention of chronic rejection who presented with 5 days of confusion, lethargy and lightheadedness. He was diagnosed with AbNAE after an extensive workup and recovered fully after high-dose corticosteroids. Our case highlights the importance of recognising the association between chronic immunosuppression and autoimmune encephalitis. Autoimmune encephalitis, even in the absence of characterised antibodies, should be considered when transplant recipients present with central neurologic symptoms.
Collapse
Affiliation(s)
- Jeffrey Spindel
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Matthew Heckroth
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Luis Marsano
- Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
8
|
Toda J, Maeda T, Akuta K, Kusakabe S, Ueda T, Fujita J, Shibayama H, Oritani K, Takahashi Y, Kanakura Y. Limbic encephalitis with antibodies to N-methyl-d-aspartate (NMDA)-type glutamate receptor after allogeneic transplantation. Int J Hematol 2020; 112:254-257. [DOI: 10.1007/s12185-020-02859-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 11/29/2022]
|