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Wu X, Zhang H, Shi M, Fang S. Clinical features in antiglycine receptor antibody-related disease: a case report and update literature review. Front Immunol 2024; 15:1387591. [PMID: 38953026 PMCID: PMC11215014 DOI: 10.3389/fimmu.2024.1387591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/06/2024] [Indexed: 07/03/2024] Open
Abstract
Background and objectives Antiglycine receptor (anti-GlyR) antibody mediates multiple immune-related diseases. This study aimed to summarize the clinical features to enhance our understanding of anti-GlyR antibody-related disease. Methods By collecting clinical information from admitted patients positive for glycine receptor (GlyR) antibody, the clinical characteristics of a new patient positive for GlyR antibody were reported in this study. To obtain additional information regarding anti-GlyR antibody-linked illness, clinical data and findings on both newly reported instances in this study and previously published cases were merged and analyzed. Results A new case of anti-GlyR antibody-related progressive encephalomyelitis with rigidity and myoclonus (PERM) was identified in this study. A 20-year-old man with only positive cerebrospinal fluid anti-GlyR antibody had a good prognosis with first-line immunotherapy. The literature review indicated that the common clinical manifestations of anti-GlyR antibody-related disease included PERM or stiff-person syndrome (SPS) (n = 179, 50.1%), epileptic seizure (n = 94, 26.3%), and other neurological disorders (n = 84, 24.5%). Other neurological issues included demyelination, inflammation, cerebellar ataxia and movement disorders, encephalitis, acute psychosis, cognitive impairment or dementia, celiac disease, Parkinson's disease, neuropathic pain and allodynia, steroid-responsive deafness, hemiballism/tics, laryngeal dystonia, and generalized weakness included respiratory muscles. The group of PERM/SPS exhibited a better response to immunotherapy than others. Conclusions The findings suggest the presence of multiple clinical phenotypes in anti-GlyR antibody-related disease. Common clinical phenotypes include PERM, SPS, epileptic seizure, and paraneoplastic disease. Patients with RERM/SPS respond well to immunotherapy.
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Affiliation(s)
- Xiaoke Wu
- Department of Neurology, Neuroscience Centre, The First Hospital of Jilin University, Changchun, China
| | - Haifeng Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengmeng Shi
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shaokuan Fang
- Department of Neurology, Neuroscience Centre, The First Hospital of Jilin University, Changchun, China
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2
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Kosek S, Burman J, Punga AR. Antibody-positive autoimmune encephalitis and paraneoplastic neurological syndrome: A Swedish case series. Brain Behav 2024; 14:e3534. [PMID: 38702897 PMCID: PMC11069023 DOI: 10.1002/brb3.3534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVE This study aimed to explore the clinical characteristics and temporal disease course of patients with autoimmune encephalitis (AE) and paraneoplastic neurological syndrome (PNS) in Sweden. METHODS Thirty-seven antibody-positive AE and PNS cases were identified in the Healthcare region Mid Sweden between 2015 and 2019. Clinical data were collected through a retrospective review of electronic health records. Patients were divided into three subgroups based on antibody type: neuronal surface antibodies (NSAbs), onconeural antibodies, and anti-GAD65 antibodies. RESULTS Nineteen patients had NSAbs, 11 onconeural antibodies, and seven anti-GAD65 antibodies. Anti-LGI1 and anti-NMDAR were the most frequently detected NSAbs, with anti-NMDAR cases having an older-than-expected age distribution (median age 40, range 17-72). Only 11 of 32 (30%) of patients had findings suggesting encephalitis on initial MRI, but 28 of 31 (90%) had pathological findings on initial cerebrospinal fluid analysis. All patients but one had abnormal EEG findings. Median time to immunotherapy was comparable among the three subgroups, whereas patients with anti-LGI1, anti-CASPR2, and anti-IgLON5 had an eightfold longer time to immunotherapy than anti-NMDAR and anti-GABA-B (p = .0016). There was a seasonal variation in onset for patients with non-tumor-related NSAbs and anti-GAD65 antibodies, with most patients (72%) falling ill in spring or summer. CONCLUSION Swedish patients with AE and PNS had similar clinical characteristics as previously described cohorts from other geographical regions except for anti-NMDAR encephalitis, with older onset than expected. The onset of non-tumor-related AE occurred predominantly in the warm seasons, and AE with a more insidious onset was associated with delayed treatment initiation.
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Affiliation(s)
- Sonja Kosek
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- Centre for Clinical Research and EducationKarlstadSweden
| | - Joachim Burman
- Department of Medical SciencesUppsala UniversityUppsalaSweden
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Rosenberg R, Thorpy MJ, Doghramji K, Morse AM. Brain fog in central disorders of hypersomnolence: a review. J Clin Sleep Med 2024; 20:643-651. [PMID: 38217475 PMCID: PMC10985301 DOI: 10.5664/jcsm.11014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 01/15/2024]
Abstract
Brain fog is an undefined term describing a cluster of symptoms related to fatigue and impaired memory, attention, and concentration. Brain fog or brain fog-like symptoms have been reported in central disorders of hypersomnolence and in a range of seemingly unrelated disorders, including coronavirus disease 2019, major depressive disorder, multiple sclerosis, lupus, and celiac disease. This narrative review summarizes current evidence and proposes a consensus definition for brain fog. Brain fog is prevalent in narcolepsy and idiopathic hypersomnia, with more than three-quarters of patients with either disorder reporting this symptom in a registry study; it has also been reported as particularly difficult to treat in idiopathic hypersomnia. Studies directly evaluating brain fog are rare; tools for evaluating this symptom cluster typically are patient reports, with few objective measures validated in any disorder. Evaluating brain fog is further complicated by confounding symptoms, such as excessive daytime sleepiness, which is a hallmark of hypersomnolence disorders. No treatments specifically address brain fog. The paucity of literature, assessment tools, and medications for brain fog highlights the need for research leading to better disambiguation and treatment. Until a clear consensus definition is established, we propose brain fog in hypersomnia disorders be defined as a cognitive dysfunction that may or may not be linked with excessive sleepiness, related to an underlying neuronal dysfunction, which reduces concentration and impairs information processing, leading to a complaint of lack of clarity of mental thinking and awareness. CITATION Rosenberg R, Thorpy MJ, Doghramji K, Morse AM. Brain fog in central disorders of hypersomnolence: a review. J Clin Sleep Med. 2024;20(4):643-651.
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Affiliation(s)
| | | | - Karl Doghramji
- Jefferson Sleep Disorders Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anne Marie Morse
- Department of Child Neurology and Sleep Medicine, Geisinger Medical Center, Janet Weis Children’s Hospital, Danville, Pennsylvania
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Khannanova AN, Brylev LV, Prusova AA, Aksenova EV, Kondrasheva EA, Kovaleva IS. [Autoimmune encephalitis: psychiatric aspects]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:20-27. [PMID: 38465807 DOI: 10.17116/jnevro202412402120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Autoimmune encephalitis is a group of diseases researched by both neurologists and psychiatrists. Despite a large number of studies and practical recommendations, the differential diagnosis and early diagnostics still remains an important issue. The most difficult to diagnose are cases that debut as mental disorders and/or occur without neurological symptoms. The literature review presents the current state of the problem with an emphasis on the practice of a psychiatrist.
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Affiliation(s)
- A N Khannanova
- Gannushkin Psychiatric Clinical Hospital No. 4, Moscow, Russia
- Russian Biotechnological University, Moscow, Russia
| | - L V Brylev
- V.M. Bujanov Moscow Clinical Hospital, Moscow, Russia
- Institute of Higher Nervous Activity and Neurophysiology, Moscow, Russia
| | - A A Prusova
- Gannushkin Psychiatric Clinical Hospital No. 4, Moscow, Russia
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5
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Ter Horst L, van Zeggeren IE, Olie SE, van de Beek D, Brouwer MC. Predictors of unfavourable outcome in adults with suspected central nervous system infections: a prospective cohort study. Sci Rep 2023; 13:21250. [PMID: 38040800 PMCID: PMC10692224 DOI: 10.1038/s41598-023-48472-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
Suspected central nervous system (CNS) infections may pose a diagnostic challenge, and often concern severely ill patients. We aim to identify predictors of unfavourable outcome to prioritize diagnostics and treatment improvements. Unfavourable outcome was assessed on the Glasgow Outcome Scale at hospital discharge, defined by a score of 1 to 4. Of the 1152 episodes with suspected CNS infection, from two Dutch prospective cohorts, the median age was 54 (IQR 37-67), and 563 episodes (49%) occurred in women. The final diagnoses were categorized as CNS infection (N = 358 episodes, 31%), CNS inflammatory disease (N = 113, 10%), non-infectious non-inflammatory neurological disorder (N = 388, 34%), non-neurological infection (N = 252, 22%), and other systemic disorder (N = 41, 4%). Unfavourable outcome occurred in 412 of 1152 (36%), and 99 died (9%). Predictors for unfavourable outcomes included advanced age, absence of headache, tachycardia, altered mental state, focal cerebral deficits, cranial nerve palsies, low thrombocytes, high CSF protein, and the final diagnosis of CNS inflammatory disease (odds ratio 4.5 [95% confidence interval 1.5-12.6]). Episodes suspected of having a CNS infection face high risk of experiencing unfavourable outcome, stressing the urgent need for rapid and accurate diagnostics. Amongst the suspected CNS infection group, those diagnosed with CNS inflammatory disease have the highest risk.
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Affiliation(s)
- Liora Ter Horst
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Ingeborg E van Zeggeren
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Sabine E Olie
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam UMC, Department of Neurology, Amsterdam Neuroscience, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1105 AZ, Amsterdam, The Netherlands.
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6
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Hoffer J, Frem W, Alkana J, Chih C, Liu AK. SOX1 Antibody in a Patient With Serotonin Syndrome. Cureus 2023; 15:e48516. [PMID: 37946854 PMCID: PMC10631746 DOI: 10.7759/cureus.48516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/12/2023] Open
Abstract
SOX1 antibody is an autoimmune antibody, usually associated with Lambert-Eaton myasthenic syndrome, paraneoplastic conditions, and encephalitis. This antibody has also been found among psychiatric patients. However, the role of SOX1 antibody in serotonin syndrome has not yet been defined, as a literature search yielded no results. Therefore, the treatment as such has unknown clinical significance. In this case study, we report a patient with SOX1 antibodies and altered mental status out of proportion to serotonin syndrome whose symptoms improved with simultaneous treatment of both conditions.
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Affiliation(s)
- Julia Hoffer
- Internal Medicine, Adventist Health White Memorial, Los Angeles, USA
| | - William Frem
- Internal Medicine, Adventist Health White Memorial, Los Angeles, USA
| | - Jessica Alkana
- Neurology, Adventist Health White Memorial, Los Angeles, USA
| | - Charisse Chih
- Neurology, Adventist Health White Memorial, Los Angeles, USA
| | - Antonio K Liu
- Neurology, Adventist Health White Memorial, Los Angeles, USA
- Neurology, Loma Linda University School of Medicine, Loma Linda, USA
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de Freitas Dias B, Fieni Toso F, Slhessarenko Fraife Barreto ME, de Araújo Gleizer R, Dellavance A, Kowacs PA, Teive H, Spitz M, Freire Borges Juliano A, Januzi de Almeida Rocha L, Braga-Neto P, Ribeiro Nóbrega P, Oliveira-Filho J, Maciel Dias R, de Oliveira Godeiro Júnior C, Martins Maia F, Barbosa Thomaz R, Santos ML, Sousa de Melo E, da Nóbrega Júnior AW, Lin K, Graziani Povoas Barsottini O, Endmayr V, Coelho Andrade LE, Höftberger R, Almeida Dutra L. Brazilian autoimmune encephalitis network (BrAIN): antibody profile and clinical characteristics from a multicenter study. Front Immunol 2023; 14:1256480. [PMID: 37954587 PMCID: PMC10634608 DOI: 10.3389/fimmu.2023.1256480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/04/2023] [Indexed: 11/14/2023] Open
Abstract
Background The frequency of antibodies in autoimmune encephalitis (AIE) may vary in different populations, however, data from developing countries are lacking. To describe the clinical profile of AIE in Brazil, and to evaluate seasonality and predictors of AIE in adult and pediatric patients. Methods We evaluated patients with possible AIE from 17 centers of the Brazilian Autoimmune Encephalitis Network (BrAIN) between 2018 and 2022. CSF and serum were tested with TBAs and CBAs. Data on clinical presentation, complementary investigation, and treatment were compiled. Seasonality and predictors of AIE in adult and pediatric populations were analyzed. Results Of the 564 patients, 145 (25.7%) were confirmed as seropositive, 69 (12.23%) were seronegative according to Graus, and 58% received immunotherapy. The median delay to diagnosis confirmation was 5.97 ± 10.3 months. No seasonality variation was observed after 55 months of enrolment. The following antibodies were found: anti-NMDAR (n=79, 54%), anti-MOG (n=14, 9%), anti-LGI1(n=12, 8%), anti-GAD (n=11, 7%), anti-GlyR (n=7, 4%), anti-Caspr2 (n=6, 4%), anti-AMPAR (n=4, 2%), anti-GABA-BR (n=4, 2%), anti-GABA-AR (n=2, 1%), anti-IgLON5 (n=1, 1%), and others (n=5, 3%). Predictors of seropositive AIE in the pediatric population (n=42) were decreased level of consciousness (p=0.04), and chorea (p=0.002). Among adults (n=103), predictors of seropositive AIE were movement disorders (p=0.0001), seizures (p=0.0001), autonomic instability (p=0.026), and memory impairment (p=0.001). Conclusion Most common antibodies in Brazilian patients are anti-NMDAR, followed by anti-MOG and anti-LGI1. Only 26% of the possible AIE patients harbor antibodies, and 12% were seronegative AIE. Patients had a 6-month delay in diagnosis and no seasonality was found. Findings highlight the barriers to treating AIE in developing countries and indicate an opportunity for cost-effect analysis. In this scenario, some clinical manifestations help predict seropositive AIE such as decreased level of consciousness, chorea, and dystonia among children, and movement disorders and memory impairment among adults.
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Affiliation(s)
| | | | | | | | | | | | - Helio Teive
- Hospital Universitário da Universidade Federal do Paraná, Curitiba, Brazil
| | - Mariana Spitz
- Hospital Universitário Pedro Ernesto da Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | | | | | | | | | | | | | - Katia Lin
- Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | | | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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8
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Gillon S, Chan M, Chen J, Guterman EL, Wu X, Glastonbury CM, Li Y. MR Imaging Findings in a Large Population of Autoimmune Encephalitis. AJNR Am J Neuroradiol 2023; 44:799-806. [PMID: 37385678 PMCID: PMC10337613 DOI: 10.3174/ajnr.a7907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Autoimmune encephalitis is a rare condition in which autoantibodies attack neuronal tissue, causing neuropsychiatric disturbances. This study sought to evaluate MR imaging findings associated with subtypes and categories of autoimmune encephalitis. MATERIALS AND METHODS Cases of autoimmune encephalitis with specific autoantibodies were identified from the medical record (2009-2019). Cases were excluded if no MR imaging of the brain was available, antibodies were associated with demyelinating disease, or >1 concurrent antibody was present. Demographics, CSF profile, antibody subtype and group (group 1 intracellular antigen or group 2 extracellular antigen), and MR imaging features at symptom onset were reviewed. Imaging and clinical features were compared across antibody groups using χ2 and Wilcoxon rank-sum tests. RESULTS Eighty-five cases of autoimmune encephalitis constituting 16 distinct antibodies were reviewed. The most common antibodies were anti-N-methyl-D-aspartate (n = 41), anti-glutamic acid decarboxylase (n = 7), and anti-voltage-gated potassium channel (n = 6). Eighteen of 85 (21%) were group 1; and 67/85 (79%) were group 2. The median time between MR imaging and antibody diagnosis was 14 days (interquartile range, 4-26 days). MR imaging had normal findings in 33/85 (39%), and 20/33 (61%) patients with normal MRIs had anti-N-methyl-D-aspartate receptor antibodies. Signal abnormality was most common in the limbic system (28/85, 33%); 1/68 (1.5%) had susceptibility artifacts. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2. CONCLUSIONS Sixty-one percent of patients with autoimmune encephalitis had abnormal brain MR imaging findings at symptom onset, most commonly involving the limbic system. Susceptibility artifact is rare and makes autoimmune encephalitis less likely as a diagnosis. Brainstem and cerebellar involvement were more common in group 1, while leptomeningeal enhancement was more common in group 2.
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Affiliation(s)
- S Gillon
- From the School of Medicine (S.G., J.C.)
| | - M Chan
- Department of Radiology (M.C.), University of Toronto, Toronto, Ontario, Canada
| | - J Chen
- From the School of Medicine (S.G., J.C.)
| | | | - X Wu
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - C M Glastonbury
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
| | - Y Li
- Department of Radiology and Biomedical Imaging (X.W., C.M.G., Y.L.), University of California San Francisco, San Francisco, California
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Venkatesan A, Habis R, Geocadin RG. Approach to acute encephalitis in the intensive care unit. Curr Opin Crit Care 2023; 29:89-98. [PMID: 36794940 DOI: 10.1097/mcc.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Recent years have seen a dramatic increase in the identification of autoimmune encephalitis (AE) and the emergence of new causes of infectious encephalitis (IE). However, management of these patients remains challenging, with many requiring care in intensive care units. Here, we describe recent advances in the diagnosis and management of acute encephalitis. RECENT FINDINGS Advances in the identification of clinical presentations, neuroimaging biomarkers, and electroencephalogram patterns have enabled more rapid diagnosis of encephalitis. Newer modalities such as meningitis/encephalitis multiplex PCR panels, metagenomic next-generation sequencing, and phage display-based assays are being evaluated in an effort to improve detection of autoantibodies and pathogens. Specific advances in the treatment of AE include establishment of a systematic approach to first-line therapies and the development of newer second-line modalities. The role of immunomodulation and its applications in IE are actively being investigated. In the ICU, particular attention to status epilepticus, cerebral edema, and dysautonomia may improve outcomes. SUMMARY Substantial diagnostic delays still occur, with many cases left without an identified etiology. Antiviral therapies remain scarce, and optimal treatment regimens for AE still need to be clarified. Nevertheless, our understanding of diagnostic and therapeutic approaches to encephalitis is rapidly evolving.
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Affiliation(s)
| | - Ralph Habis
- Johns Hopkins Encephalitis Center, Department of Neurology
| | - Romergryko G Geocadin
- Johns Hopkins Encephalitis Center, Department of Neurology
- Departments of Neurosurgery and Anaesthesia/Critical Care, Johns Hopkins University School of Medicine, Maryland, USA
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10
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Anti-titin antibodies are associated with myocarditis in patients with myasthenia gravis. J Neurol 2023; 270:1457-1465. [PMID: 36383260 DOI: 10.1007/s00415-022-11485-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) can affect cardiac muscles with variable presentations. Myocarditis is a rare but potentially serious cardiac manifestation of MG. Although thymomas and anti-titin antibodies have been suggested as risk factors for myocarditis in patients with MG, their independent influence on myocarditis has rarely been assessed. METHODS A retrospective chart review was conducted on 247 patients diagnosed with MG who were tested for anti-titin antibodies. Myocarditis was diagnosed on the basis of the European Society of Cardiology 2013 Task Force criteria for clinically suspected myocarditis. Patients were classified into myocarditis-positive and myocarditis-negative groups. Multivariate analysis was performed to analyze the risk factors for myocarditis. RESULTS Of the 247 patients, 25 (10.1%) were myocarditis-positive and 222 (89.9%) were myocarditis-negative. Anti-titin antibody positivity was higher in the myocarditis-positive group than in the myocarditis-negative group (68.0% vs. 28.4%, p < 0.001). A history of MG crisis was more frequent in the myocarditis-positive group than in the myocarditis-negative group (64.0% vs. 10.4%, p < 0.001). The presence of anti-titin antibodies (odds ratio [OR] 7.906; confidence interval [CI] 2.460-25.401) and MG crisis (OR 24.807; CI 7.476-82.311) was significantly associated with myocarditis. The Cox regression model showed that the anti-titin antibody levels (hazard ratio [HR] 3.639; 95% CI 1.557-8.505) and MG crisis (HR 6.137; 95% CI 2.639-14.272) were significant risk factors for the development of myocarditis. CONCLUSION The presence of anti-titin antibody was associated with myocarditis in patients with MG, whereas thymoma was not. Although rare, early suspicion of myocarditis could be required, especially in patients with MG having anti-titin antibodies.
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11
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Bjerknes TL, Steihaug OM, Haugen M, Hjelland IE, Vedeler CA. Case report: Pain in anti-DPPX encephalitis. Front Neurol 2022; 13:1091688. [PMID: 36588910 PMCID: PMC9794743 DOI: 10.3389/fneur.2022.1091688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Encephalitis due to antibodies targeting dipeptidyl-peptidase-like protein 6 (DPPX), a potassium channel subunit, is rare. The illness is typically characterized by a triad of weight loss, CNS hyperexcitability and cognitive symptoms, but recent reports suggest that the clinical picture may be more heterogeneous. Here, we describe the case of a 63-year-old female who was admitted to the hospital with severe extremity pain, which had been preceded by diarrhea and weight loss. She later developed cognitive changes, and her general condition rapidly deteriorated. Extensive workup did not reveal gastrointestinal illness or underlying malignancies. MRI of the brain was normal. Analyses of blood and cerebrospinal fluid showed normal cell counts but high titres of DPPX antibodies in blood and cerebrospinal fluid. The patient was treated with intravenous methylprednisolone followed by rituximab. At 1-year follow-up, she was without pain and had completely recovered. In this case, DPPX-associated autoimmune encephalitis was dominated by severe extremity pain, illustrating that sensory symptoms may be one of the main complaints in these patients. It is important for clinicians to be aware of the heterogeneous clinical picture in this serious condition, since correct diagnosis and treatment with immunosuppressants are associated with favorable prognosis.
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Affiliation(s)
- Tale L. Bjerknes
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,*Correspondence: Tale L. Bjerknes
| | | | - Mette Haugen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ina Elen Hjelland
- Department of Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | - Christian Alexander Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Zhang YZ, Ni Y, Gao YN, Shen DD, He L, Yin D, Meng HY, Zhou QM, Hu J, Chen S. Anti-IgLON5 disease: a novel topic beyond neuroimmunology. Neural Regen Res 2022; 18:1017-1022. [PMID: 36254983 PMCID: PMC9827781 DOI: 10.4103/1673-5374.355742] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Anti-IgLON5 disease is a recently defined autoimmune disorder of the nervous system associated with autoantibodies against IgLON5. Given its broad clinical spectrum and extremely complex pathogenesis, as well as difficulties in its early diagnosis and treatment, anti-IgLON5 disease has become the subject of considerable research attention in the field of neuroimmunology. Anti-IgLON5 disease has characteristics of both autoimmunity and neurodegeneration due to the unique activity of the anti-IgLON5 antibody. Neuropathologic examination revealed the presence of a tauopathy preferentially affecting the hypothalamus and brainstem tegmentum, potentially broadening our understanding of tauopathies. In contrast to that seen with other autoimmune encephalitis-related antibodies, basic studies have demonstrated that IgLON5 antibody-induced neuronal damage and degeneration are irreversible, indicative of a potential link between autoimmunity and neurodegeneration in anti-IgLON5 disease. Herein, we comprehensively review and discuss basic and clinical studies relating to anti-IgLON5 disease to better understand this complicated disorder.
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Affiliation(s)
- Yi-ZongHeng Zhang
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - You Ni
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Ning Gao
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ding-Ding Shen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Lu He
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dou Yin
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huan-Yu Meng
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin-Ming Zhou
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
| | - Ji Hu
- Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China,School of Life Science and Technology, ShanghaiTech University, Shanghai, China,Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
| | - Sheng Chen
- Department of Neurology & Institute of Neurology, Ruijin Hospital, Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China,Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China,Correspondence to: Sheng Chen, ; Ji Hu, ; Qin-Ming Zhou, .
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Abstract
PURPOSE OF REVIEW Autoimmune encephalitis (AE) refers to immune-mediated neurological syndromes often characterised by the detection of pathogenic autoantibodies in serum and/or cerebrospinal fluid which target extracellular epitopes of neuroglial antigens. There is increasing evidence these autoantibodies directly modulate function of their antigens in vivo. Early treatment with immunotherapy improves outcomes. Yet, these patients commonly exhibit chronic disability. Importantly, optimal therapeutic strategies at onset and during escalation remain poorly understood. In this review of a rapidly emerging field, we evaluate recent studies on larger cohorts, registries, and meta-analyses to highlight existing evidence for contemporary therapeutic approaches in AE. RECENT FINDINGS We highlight acute and long-term treatments used in specific AE syndromes, exemplify how understanding disease pathogenesis can inform precision therapy and outline challenges of defining disability outcomes in AE. SUMMARY Early first-line immunotherapies, including corticosteroids and plasma exchange, improve outcomes, with emerging evidence showing second-line immunotherapies (especially rituximab) reduce relapse rates. Optimal timing of immunotherapy escalation remains unclear. Routine reporting of outcome measures which incorporate cognitive impairment, fatigue, pain, and mental health will permit more accurate quantification of residual disability and comprehensive comparisons between international multicentre cohorts, and enable future meta-analyses with the aim of developing evidence-based therapeutic guidelines.
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Affiliation(s)
- Benjamin P Trewin
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Isaak Freeman
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead; Sydney Medical School and Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Neurology, Concord Hospital, Sydney, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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14
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Gora H, Smith S, Wilson I, Preston-Thomas A, Ramsamy N, Hanson J. The epidemiology and outcomes of central nervous system infections in Far North Queensland, tropical Australia; 2000-2019. PLoS One 2022; 17:e0265410. [PMID: 35312713 PMCID: PMC8936475 DOI: 10.1371/journal.pone.0265410] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background The epidemiology of central nervous system (CNS) infections in tropical Australia is incompletely defined. Methods A retrospective study of all individuals in Far North Queensland, tropical Australia, who were diagnosed with a CNS infection between January 1, 2000, and December 31, 2019. The microbiological aetiology of the infection was correlated with patients’ demographic characteristics and their clinical course. Results There were 725 cases of CNS infection during the study period, meningitis (77.4%) was the most common, followed by brain abscess (11.6%), encephalitis (9.9%) and spinal infection (1.1%). Infants (24.3%, p<0.0001) and Aboriginal and Torres Strait Islander Australians (175/666 local residents, 26.3%, p<0.0001) were over-represented in the cohort. A pathogen was identified in 513 cases (70.8%); this was viral in 299 (41.2%), bacterial in 175 (24.1%) and fungal in 35 (4.8%). Cryptococcal meningitis (24 cases) was diagnosed as frequently as pneumococcal meningitis (24 cases). There were only 2 CNS infections with a S. pneumoniae serotype in the 13-valent pneumococcal vaccine after its addition to the National Immunisation schedule in 2011. Tropical pathogens–including Cryptococcus species (9/84, 11%), Mycobacterium tuberculosis (7/84, 8%) and Burkholderia pseudomallei (5/84, 6%)–were among the most common causes of brain abscess. However, arboviral CNS infections were rare, with only one locally acquired case—a dengue infection in 2009—diagnosed in the entire study period. Intensive Care Unit admission was necessary in 14.3%; the overall case fatality rate was 4.4%. Conclusion Tropical pathogens cause CNS infections as commonly as traditional bacterial pathogens in this region of tropical Australia. However, despite being highlighted in the national consensus guidelines, arboviruses were identified very rarely. Prompt access to sophisticated diagnostic and supportive care in Australia’s well-resourced public health system is likely to have contributed to the cohort’s low case-fatality rate.
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Affiliation(s)
- Hannah Gora
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
- * E-mail:
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Ian Wilson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Nicole Ramsamy
- Weipa Integrated Health Service, Weipa, Queensland, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
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15
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Dogan N, Subasi H, Erbasan ZI, Tahillioglu A, Kanmaz S, Kose S, Ozbaran B, Serin HM. Understanding and management of anti-N-methyl-D-aspartate receptor encephalitis from a child psychiatry perspective: report of five cases. Neurocase 2022; 28:239-245. [PMID: 35672904 DOI: 10.1080/13554794.2022.2086468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune entity in psychiatry literature that occurs when antibodies attack NMDA-type glutamate receptors in the brain. Principle clinical features include a neurological domain such as seizure, orofacial dyskinesia, dystonia, and choreic-like movements of extremities. Also the psychiatric manifestations of this form of encephalitis may vary from psychotic-like symptoms to mood symptoms like depression or mania. Herein we report on five female child cases diagnosed with anti-NMDAR encephalitis, presented with both neurological and psychiatric clinical picture, and highlight the trajectory of disorder from a psychiatric perspective.
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Affiliation(s)
- Nurhak Dogan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Hilal Subasi
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Zeynep Irem Erbasan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Akin Tahillioglu
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Seda Kanmaz
- Department of Child Neurology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sezen Kose
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Burcu Ozbaran
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Hepsen Mine Serin
- Department of Child Neurology, Faculty of Medicine, Ege University, Izmir, Turkey
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16
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Vaux A, Robinson K, Saglam B, Cheuk N, Kilpatrick T, Evans A, Monif M. Autoimmune Encephalitis in Long-Standing Schizophrenia: A Case Report. Front Neurol 2022; 12:810926. [PMID: 35222231 PMCID: PMC8873086 DOI: 10.3389/fneur.2021.810926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/27/2021] [Indexed: 01/17/2023] Open
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor antibody (anti-NMDAR Ab)-mediated encephalitis is an autoimmune disorder involving the production of antibodies against NMDARs in the central nervous system that leads to neurological or psychiatric dysfunction. Initially described as a paraneoplastic syndrome in young women with teratomas, increased testing has found it to be a heterogeneous condition that affects both the sexes with varying clinical manifestations, severity, and aetiology. This case report describes a 67-year-old man with a 40-year history of relapsing, severe, treatment-refractory schizophrenia. Due to the worsening of his condition during a prolonged inpatient admission for presumed relapse of psychosis, a revisit of the original diagnosis was considered with extensive investigations performed including an autoimmune panel. This revealed anti-NMDAR Abs in both the serum and cerebrospinal fluid on two occasions. Following treatment with intravenous immunoglobulin and methylprednisolone, he demonstrated rapid symptom improvement. This is a rare case of a long-standing psychiatric presentation with a preexisting diagnosis of schizophrenia subsequently found to have anti-NMDAR Ab-mediated encephalitis. Whether the case is one of initial NMDAR encephalitis vs. overlap syndrome is unknown. Most importantly, this case highlights the need for vigilance and balanced consideration for treatment in cases of long-standing psychiatric presentation where the case remains treatment refractory to antipsychotics or when atypical features including seizures and autonomic dysfunction or focal neurology are observed.
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Affiliation(s)
- Amy Vaux
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- *Correspondence: Amy Vaux
| | - Karen Robinson
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Burcu Saglam
- Department of Psychiatry, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Nathan Cheuk
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Trevor Kilpatrick
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Evans
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mastura Monif
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
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17
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Kang Q, Liao H, Yang L, Fang H, Hu W, Wu L. Clinical Characteristics and Short-Term Prognosis of Children With Antibody-Mediated Autoimmune Encephalitis: A Single-Center Cohort Study. Front Pediatr 2022; 10:880693. [PMID: 35874583 PMCID: PMC9304965 DOI: 10.3389/fped.2022.880693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/20/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The incidence and prevalence of autoimmune encephalitis (AE) is gradually increasing in pediatric patients (between the ages of 3 months and 16 years). The aim of this retrospective observational study was to investigate the clinical characteristics and short-term prognosis of children with antibody-mediated AE at Hunan Children's Hospital. METHODS Antibody analysis of blood and/or cerebrospinal fluid was performed in suspected AE patients admitted to the Department of Neurology, Hunan Children's Hospital from June 2014 to June 2021. Ultimately, 103 patients were diagnosed with antibody-mediated AE and were enrolled in this study. Clinical data and corresponding demographic, clinical characteristics, laboratory and imaging data, treatment, and prognosis data were collected and analyzed. RESULTS In our study, 103 AE patients with antibody-positive were identified. The main subtype of AE in our cohort was anti-NMDAR encephalitis. Few patients have anti-CASPR2 encephalitis, anti-GABABR encephalitis, or anti-LGI1 encephalitis. In our AE patients, the most common clinical manifestations were behavioral symptoms, seizures, and involuntary movements, with seizures being the most common initial symptom. All patients underwent brain magnetic resonance imaging (MRI) and electroencephalography (EEG). Forty-five (43.7%) patients had abnormal MRI findings. And 96 (93.2%) patients had abnormal EEG results. All 103 patients were given first-line immunotherapy, 21 of which were also treated with the combination of the second-line immunotherapy. All surviving patients were followed up for at least 6 months. Seventy-seven patients recovered completely, 23 had sequelae of different degrees, and 3 died. Eight patients had one or more relapses during the follow-up period. CONCLUSIONS AE is a treatable disease that can occur in children of all ages. The mortality rate is low, as most patients have a good response to immune therapy. Compared with the older children, infants and young children (≤ 3 years old) with anti-NMDAR encephalitis have a higher incidence of fever and status epilepticus, more severe condition, higher PICU admission rate and worse prognosis. AE patients with high maximum mRS scores and PICU admissions may require second-line immunotherapy.
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Affiliation(s)
- Qingyun Kang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Hongmei Liao
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Liming Yang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Hongjun Fang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Wenjing Hu
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Liwen Wu
- Department of Neurology, Hunan Children's Hospital, Changsha, China
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