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Endres D, Perlov E, Stich O, Rauer S, Maier S, Waldkircher Z, Lange T, Mader I, Meyer PT, Tebartz van Elst L. Hypoglutamatergic state is associated with reduced cerebral glucose metabolism in anti-NMDA receptor encephalitis: a case report. BMC Psychiatry 2015; 15:186. [PMID: 26231521 PMCID: PMC4522073 DOI: 10.1186/s12888-015-0552-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/06/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis was first described in 2005 in association with ovarian teratoma. The diagnostic workup of this common autoimmune encephalitis includes cerebrospinal fluid analysis, electroencephalography, magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (FDG-PET). In addition to standard diagnostics, we performed metabolic investigations using proton magnet resonance spectroscopy ((1)H-MRS). CASE PRESENTATION We describe the case of a non-limbic anti-NMDAR encephalitis with a long course of disease (21 months). Laboratory diagnostics showed antibodies against NMDAR; an MRI revealed unspecific findings. (1)H-MRS indicated a hypoglutamatergic state in the left prefrontal cortex associated with a left hemispherical hypometabolism on FDG-PET. Despite the long course of disease, immunosuppressive therapy with methylprednisolone and azathioprine led to almost complete remission of clinical symptoms. Clinical improvement developed in parallel with remarkable normalization of cerebral glucose metabolism on FDG-PET. CONCLUSION This case of long-lasting extra-limbic anti-NMDAR encephalitis is of high clinical relevance. First, it illustrates that a very good outcome is possible even if adequate therapy is started only 21 months after the onset of severe symptoms. Second, it provides valuable insights into the pathophysiology of such anti-NMDAR encephalitis; these insights prove that anti-NMDAR encephalitis is linked not only to hyperglutamatergic signals but also to hypoglutamatergic states. These findings, contradictory at first glance, can be integrated within the model of excitatory/inhibitory imbalance and local area network inhibition.
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Affiliation(s)
- Dominique Endres
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Evgeniy Perlov
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Oliver Stich
- Department of Neurology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Sebastian Rauer
- Department of Neurology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Simon Maier
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany. .,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Zora Waldkircher
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104, Freiburg, Germany.
| | - Thomas Lange
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Irina Mader
- Department of Neuroradiology, University Medical Center Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Philipp Tobias Meyer
- Department of Nuclear Medicine, University Medical Center Freiburg, Hugstetter Str. 64, 79106, Freiburg, Germany.
| | - Ludger Tebartz van Elst
- Section of Experimental Neuropsychiatry, Department for Psychiatry& Psychotherapy, University Medical Center Freiburg, Hauptstr. 5, 79104 Freiburg, Germany ,Freiburg Brain Imaging, University Medical Center Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
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Varley J, Vincent A, Irani SR. Clinical and experimental studies of potentially pathogenic brain-directed autoantibodies: current knowledge and future directions. J Neurol 2014; 262:1081-95. [PMID: 25491076 PMCID: PMC4412383 DOI: 10.1007/s00415-014-7600-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/27/2014] [Indexed: 02/06/2023]
Abstract
The field of neuronal surface-directed antibody-mediated diseases of the central nervous system has dramatically expanded in the last few years and now forms an important cluster of treatable neurological conditions. In this review, we focus on three areas. First, we review the demographics, clinical features and treatment responses of these conditions. Second, we consider their pathophysiology and compare autoantibody mechanisms and their effects to genetic or pharmacological disruptions of the target antigens. Third, we discuss areas of controversy within the field, propose possible resolutions, and explore new directions for neuronal surface antibody-mediated diseases.
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Affiliation(s)
- James Varley
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
| | - Sarosh R. Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, West Wing, Level 6, Oxford, OX3 9DU UK
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Gandal MJ, Sisti J, Klook K, Ortinski PI, Leitman V, Liang Y, Thieu T, Anderson R, Pierce RC, Jonak G, Gur RE, Carlson G, Siegel SJ. GABAB-mediated rescue of altered excitatory-inhibitory balance, gamma synchrony and behavioral deficits following constitutive NMDAR-hypofunction. Transl Psychiatry 2012; 2:e142. [PMID: 22806213 PMCID: PMC3410621 DOI: 10.1038/tp.2012.69] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Reduced N-methyl-D-aspartate-receptor (NMDAR) signaling has been associated with schizophrenia, autism and intellectual disability. NMDAR-hypofunction is thought to contribute to social, cognitive and gamma (30-80 Hz) oscillatory abnormalities, phenotypes common to these disorders. However, circuit-level mechanisms underlying such deficits remain unclear. This study investigated the relationship between gamma synchrony, excitatory-inhibitory (E/I) signaling, and behavioral phenotypes in NMDA-NR1(neo-/-) mice, which have constitutively reduced expression of the obligate NR1 subunit to model disrupted developmental NMDAR function. Constitutive NMDAR-hypofunction caused a loss of E/I balance, with an increase in intrinsic pyramidal cell excitability and a selective disruption of parvalbumin-expressing interneurons. Disrupted E/I coupling was associated with deficits in auditory-evoked gamma signal-to-noise ratio (SNR). Gamma-band abnormalities predicted deficits in spatial working memory and social preference, linking cellular changes in E/I signaling to target behaviors. The GABA(B)-receptor agonist baclofen improved E/I balance, gamma-SNR and broadly reversed behavioral deficits. These data demonstrate a clinically relevant, highly translatable neural-activity-based biomarker for preclinical screening and therapeutic development across a broad range of disorders that share common endophenotypes and disrupted NMDA-receptor signaling.
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Affiliation(s)
- M J Gandal
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - J Sisti
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - K Klook
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA,Department of Psychiatry and Psychotherapy, RWTH Aachen University, Aachen, Germany
| | - P I Ortinski
- Center for Neurobiology and Behavior, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - V Leitman
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Y Liang
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - T Thieu
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - R Anderson
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - R C Pierce
- Center for Neurobiology and Behavior, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - G Jonak
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - R E Gur
- Neuropsychiatry Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - G Carlson
- Center for Neurobiology and Behavior, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - S J Siegel
- Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA,Director, Translational Neuroscience Program, Department of Psychiatry, University of Pennsylvania, Translational Research Laboratories, 125 S. 31st Street, Philadelphia, PA 19104, USA. E-mail: or
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Day GS, High SM, Cot B, Tang-Wai DF. Anti- NMDA-receptor encephalitis: case report and literature review of an under-recognized condition. J Gen Intern Med 2011; 26:811-6. [PMID: 21318640 PMCID: PMC3138579 DOI: 10.1007/s11606-011-1641-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 12/29/2010] [Accepted: 01/13/2011] [Indexed: 11/29/2022]
Abstract
Anti-N-methyl-D-aspartate receptor (anti-NMDA-R) encephalitis is an immune-mediated syndrome that remains under-recognized despite a growing body of literature. This syndrome has been predominantly described in young females with a constellation of symptoms, including personality changes, autonomic dysfunction and neurologic decompensation. It is commonly associated with mature ovarian teratomas. We describe the classic presentation of anti-NMDA-R encephalitis in three dramatically different patients: Case A, a young woman with ovarian teratoma; Case B, the eldest case reported to date; and Case C, a young male with no identifiable tumor. We review the literature summarizing the differential diagnosis, investigative approach, treatment options and challenges inherent to this disorder. We advocate good supportive care, involvement of multiple health disciplines and use of immune-modulating therapies in patient management. These cases underscore the need for increased awareness and high diagnostic suspicion when approaching the patient with suspected viral encephalitis.
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Affiliation(s)
- Gregory S Day
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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