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Wang J, Luo L, Meng Z, Ren Y, Tang M, Huang Z, Yang B, Niu Q, Zhou D, Wang M, Li J. Blood and CSF findings of cellular immunity in anti-NMDAR encephalitis. Int Immunopharmacol 2024; 130:111743. [PMID: 38430802 DOI: 10.1016/j.intimp.2024.111743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES To investigate the immunopathogenic mechanisms of anti-N-methyl-D-aspartate receptor encephalitis (NMDAR-E) by characterizing the changes of immune cells in both peripheral blood (PB) and cerebrospinal fluid (CSF) of patients with NMDAR-E. METHODS Cytology and flow cytometry were used to explore and compare different immunological parameters in PB and CSF of patients with NMDAR-E, viral encephalitis (VE) and healthy volunteers. Moreover, different models were established to assess the possibility of identifying NMDAR-E patients based on PB and CSF parameters. RESULTS The neutrophil counts and monocyte-to-lymphocyte ratios (MLR) in PB are higher in NMDAR-E patients than in both VEs and controls (P < 0.001, respectively), while the percentages of CD3 + T, CD4 + T lymphocytes, and the leukocytes count in CSF were lower in NMDAR-Es than in VEs (P < 0.01, respectively). The higher percentages of CD8 + T cells in blood and CSF were both correlated with more severe NMDAR-E (P < 0.05, respectively). The poor neurological status group had significantly higher PB leukocytes but lower CSF leukocyte count (P < 0.05). Longitudinal observations in patients with NMDAR-E showed a decreasing trend of leukocyte count, neutrophils count, neutrophil-to-monocyte ratios (NMR), and neutrophil-to-lymphocyte ratios (NLR) with the gradual recovery of neurological function. CONCLUSIONS The expression patterns of T lymphocyte subsets were different in patients with NMDAR-E and viral encephalitis. The changing trends of leukocyte and lymphocyte populations in peripheral blood and cerebrospinal fluid may provide clues for the diagnosis of different types of encephalitides, including NMDARE, and can be used as immunological markers to assess and predict the prognosis.
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Affiliation(s)
- Jierui Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Limei Luo
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Zirui Meng
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Yan Ren
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Meng Tang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Zhuochun Huang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Bin Yang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Qian Niu
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Minjin Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Jinmei Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Li S, Hu X, Wang M, Yu L, Zhang Q, Xiao J, Hong Z, Zhou D, Li J. Single-cell RNA sequencing reveals diverse B cell phenotypes in patients with anti-NMDAR encephalitis. Psychiatry Clin Neurosci 2024; 78:197-208. [PMID: 38063052 DOI: 10.1111/pcn.13627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUNDS Anti-N-methyl-D-aspartate receptor encephalitis (NMDAR-E) is a severe autoimmune disorder characterized by prominent psychiatric symptoms. Although the role of NMDAR antibodies in the disease has been extensively studied, the phenotype of B cell subsets is still not fully understood. METHODS We utilized single-cell RNA sequencing, single-cell B cell receptor sequencing (scBCR-seq), bulk BCR sequencing, flow cytometry, and enzyme-linked immunosorbent assay to analyze samples from both NMDAR-E patients and control individuals. RESULTS The cerebrospinal fluid (CSF) of NMDAR-E patients showed significantly increased B cell counts, predominantly memory B (Bm) cells. CSF Bm cells in NMDAR-E patients exhibited upregulated expression of differential expression genes (DEGs) associated with immune regulatory function (TNFRSF13B and ITGB1), whereas peripheral B cells upregulated DEGs related to antigen presentation. Additionally, NMDAR-E patients displayed higher levels of IgD- CD27- double negative (DN) cells and DN3 cells in peripheral blood (PB). In vitro, DN1 cell subsets from NMDAR-E patients differentiated into DN2 and DN3 cells, while CD27+ and/or IgD+ B cells (non-DN) differentiated into antibody-secreting cells (ASCs) and DN cells. NR1-IgG antibodies were found in B cell culture supernatants from patients. Differential expression of B cell IGHV genes in CSF and PB of NMDAR-E patients suggests potential antigen class switching. CONCLUSION B cell subpopulations in the CSF and PB of NMDAR-E patients exhibit distinct compositions and transcriptomic features. In vitro, non-DN cells from NMDAR-E can differentiate into DN cells and ASCs, potentially producing NR1-IgG antibodies. Further research is necessary to investigate the potential contribution of DN cell subpopulations to NR1-IgG antibody production.
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Affiliation(s)
- Sisi Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
| | - Xiang Hu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Minjin Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Luoting Yu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Qi Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Xiao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Shen S, Wei R, Gao Y, Yang X, Zhang G, Yan B, Xiao Z, Li J. Cortical atrophy in early-stage patients with anti-NMDA receptor encephalitis: a machine-learning MRI study with various feature extraction. Cereb Cortex 2024; 34:bhad499. [PMID: 38185983 DOI: 10.1093/cercor/bhad499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
Conventional brain magnetic resonance imaging (MRI) of anti-N-methyl-D-aspartate-receptor encephalitis (NMDARE) is non-specific, thus showing little differential diagnostic value, especially for MRI-negative patients. To characterize patterns of structural alterations and facilitate the diagnosis of MRI-negative NMDARE patients, we build two support vector machine models (NMDARE versus healthy controls [HC] model and NMDARE versus viral encephalitis [VE] model) based on radiomics features extracted from brain MRI. A total of 109 MRI-negative NMDARE patients in the acute phase, 108 HCs and 84 acute MRI-negative VE cases were included for training. Another 29 NMDARE patients, 28 HCs and 26 VE cases were included for validation. Eighty features discriminated NMDARE patients from HCs, with area under the receiver operating characteristic curve (AUC) of 0.963 in validation set. NMDARE patients presented with significantly lower thickness, area, and volume and higher mean curvature than HCs. Potential atrophy predominately presented in the frontal lobe (cumulative weight = 4.3725, contribution rate of 29.86%), and temporal lobe (cumulative weight = 2.573, contribution rate of 17.57%). The NMDARE versus VE model achieved certain diagnostic power, with AUC of 0.879 in validation set. Our research shows potential atrophy across the entire cerebral cortex in acute NMDARE patients, and MRI machine learning model has a potential to facilitate the diagnosis MRI-negative NMDARE.
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Affiliation(s)
- Sisi Shen
- Department of Neurology, West China Hospital of Sichuan University, 37 GuoXue Alley, Chengdu 610041, China
| | - Ran Wei
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Yu Gao
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Xinyuan Yang
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Guoning Zhang
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Bo Yan
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Zhuoling Xiao
- School of Information and Communication Engineering, University of Electronic Science and Technology of China No.2006, Xiyuan Ave, West Hi-Tech Zone, 611731| Chengdu, Sichuan, P.R. China
| | - Jinmei Li
- Department of Neurology, West China Hospital of Sichuan University, 37 GuoXue Alley, Chengdu 610041, China
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Ghimire S, Bhattarai M, Ghimire S, Bista KB, Sharma P, Kharel A, Gautam N. Nonparaneoplastic anti-NMDA receptor encephalitis in an adolescent girl: a case report. Ann Med Surg (Lond) 2023; 85:2010-2013. [PMID: 37229018 PMCID: PMC10205200 DOI: 10.1097/ms9.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/18/2023] [Indexed: 05/27/2023] Open
Abstract
Anti-N-methyl D-aspartate (NMDA) receptor encephalitis is an autoimmune neurologic disorder that classically presents with psychiatric, neurologic, and autonomic symptoms, often with a viral prodrome. Case presentation A 17-year-old female presented to the hospital with an 11-day history of fever, altered behavior, abnormal body movements, and altered sensorium. Upon examination, she was found to be febrile, tachycardic, and tachypneic, with a Glasgow Coma Scale score of 8. Discussion The diagnosis of anti-NMDA receptor encephalitis is usually confirmed by the presence of anti-NMDA receptor antibodies in the cerebrospinal fluid. The first-line treatment options include steroids, intravenous immunoglobulin, and plasmapheresis, while second-line therapies such as rituximab and cyclophosphamide may be necessary for some patients. While most patients respond well to treatment, complications can arise, and as in this case, death can occur. Conclusion New onset symptoms like alteration in behavior, abnormal body movement, altered sensorium, and psychiatric symptoms in a young female should raise suspicion of this disease. Immunotherapy is promising; however, anticipation and management of complication are essential in reducing mortality.
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Affiliation(s)
| | | | | | | | | | | | - Niraj Gautam
- Department of Neurology, Institute of Medicine, Tribhuvan University, Maharajgunj
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Gombolay G, Morris M, Loerinc L, Blackwell L, Howarth R. Sleep Characteristics in Pediatric Anti- N-methyl-d-aspartate (NMDA) Receptor Encephalitis: A Retrospective Cohort Study. J Child Neurol 2023; 38:298-306. [PMID: 37203168 PMCID: PMC10524468 DOI: 10.1177/08830738231173603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Background: Rates of sleep problems in children with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis are unknown. Methods: We used a retrospective observational cohort database of children with a diagnosis of NMDA receptor encephalitis at a single freestanding institution. One-year outcomes were assessed with the pediatric modified Rankin Score (mRS), with 0 to 2 as good and 3 or greater as poor outcome. Results: Ninety-five percent (39/41) of children with NMDA receptor encephalitis had sleep dysfunction at onset; 34% (11/32) reported sleep problems at 1 year. Sleep problems at onset and propofol use were not associated with poor outcomes at 1 year. Poor sleep at 1 year correlated with mRS scores (range 2-5) at 1 year. Discussion: High rates of sleep dysfunction occur in children with NMDA receptor encephalitis. Persistent sleep problems at 1 year may correlate with outcomes as assessed by mRS at 1 year. Further studies comparing the relationship of poor sleep with outcomes in NMDA receptor encephalitis are needed.
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Affiliation(s)
- Grace Gombolay
- Department of Pediatric Neurology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
| | - Morgan Morris
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
| | - Leah Loerinc
- Emory University School of Medicine, Atlanta, GA, USA
| | - Laura Blackwell
- Emory University School of Medicine, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
- Department of Pediatric Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Robyn Howarth
- Department of Pediatric Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on the world, affecting people’s lifestyle, economy, and livelihood. Recently, with the development of vaccines, the number of infected cases has decreased. Many case reports have revealed that COVID-19 may induce other serious comorbidities such as anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis. Anti-NMDA receptor encephalitis is an acute autoimmune disease that occurs more commonly in women than in men. To explore the association between COVID-19 and anti-NMDA receptor encephalitis, the microRNA (miRNA) biomarkers of COVID-19, anti-NMDA receptor encephalitis, and other related diseases from the literature are reviewed; then on the basis of these miRNA biomarkers, the relationship between COVID-19 and anti-NMDA receptor encephalitis is discussed. miRNAs are small non-coding RNAs that play important roles in cell differentiation, development, cell-cycle regulation, and apoptosis. miRNAs have been used as biological biomarkers for many diseases. The results in this study reveal that the relationship between anti-NMDA receptor encephalitis and COVID-19 infection or COVID-19 vaccination cannot be excluded; however, the risk that COVID-19 triggers the anti-NMDA receptor encephalitis is not high.
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Affiliation(s)
- Hsiuying Wang
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
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Zhao Y, Wang H, Wang M, Yuan B, Sun T, Xu Y. Relapse factors of patients of anti-N-methyl-D-aspartate receptor encephalitis. Acta Neurol Scand 2022; 145:434-441. [PMID: 34927233 DOI: 10.1111/ane.13568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The factors associated with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis relapse are yet to be elucidated. AIMS OF THE STUDY To investigate the factors associated with relapse and prognosis of anti-NMDA receptor encephalitis. METHODS This retrospective study included patients diagnosed with anti-NMDA receptor encephalitis admitted to the First Affiliated Hospital of Zhengzhou University from January 2013 to October 2019. The clinical features, auxiliary examinations, treatment regimens, and follow-up were recorded. The outcomes were relapse and 2-year disease prognosis. RESULTS A total of 160 patients were included. Consequently, 6 (5%) deaths, 34 (25.4%) relapses, and 19 (15.2%) patients had a poor prognosis (modified Rankin score (mRS) ≥3) were recorded. The multivariable analyses showed that age (p = .011), abnormal magnetic resonance imaging (MRI) (p = .019), glucocorticoid pulse (p = .009), and intracranial pressure (p = .023) were independently associated with the relapse, while age (p = .030) and central hypoventilation (p = .020) were independently associated with a poor prognosis at 2 years. CONCLUSION Glucocorticoid pulse therapy reduces the relapse of anti-NMDA receptor encephalitis. Age, abnormal MRI, and intracranial pressure are risk factors for relapse, while age and central hypoventilation are independently associated with poor prognosis.
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Affiliation(s)
- Ying‐Ying Zhao
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Hai‐Xu Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Meng Wang
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Bo Yuan
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Tong‐Wen Sun
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Yu‐Ming Xu
- The First Affiliated Hospital of Zhengzhou University Zhengzhou China
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Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. The prognosis of late-onset anti-N-methyl-D-aspartate receptor encephalitis in China. Acta Neurol Scand 2022; 145:449-455. [PMID: 34918336 DOI: 10.1111/ane.13571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/27/2021] [Accepted: 12/05/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Early-onset anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) differs from late-onset anti-NMDARE regarding clinical characteristics. Until recently, research focusing on prognosis of elder adults has been scarce and showed inconsistent results. This study aims to evaluate the prognosis of late-onset anti-NMDARE in China. MATERIALS & METHODS One hundred and twelve adults diagnosed as anti-NMDARE in four hospitals in China were reviewed retrospectively. Outcome data were assessed using modified Rankin Scale (mRS) score in short term (3 months after discharge) and long term (≥12 months after discharge). The relapse rate was also computed. Multivariable logistic regression was used to evaluate whether there are substantial differences in functional outcomes and recurrence rate across two groups. RESULTS Of the 112 patients with anti-NMDARE, 81 (72.3%) were early-onset disease and 31 (27.7%) were late-onset disease. Of these, all had short-term follow-up and 70 completed long-term follow-up. Late-onset anti-NMDARE group showed better short-term (OR 2.70, 95% CI 1.09-6.71) and long-term prognoses (OR 10.25, 95% CI 1.90-55.15). Recurrence rates were statistically different between the groups (OR 4.25, 95% CI 1.22-14.75). CONCLUSION The prognosis for anti-NMDARE in China was poorer for older adults relative to younger adults. The relapse rates were higher in late-onset group compared to early-onset group.
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Affiliation(s)
- Yueqian Sun
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Guoping Ren
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
| | - Jiechuan Ren
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
| | - Wei Shan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
- Collaborative Innovation Center for Brain Disorders Beijing Institute of Brain Disorders Capital Medical University Beijing China
| | - Xiong Han
- Department of Neurology Henan Provincial People's Hospital Henan China
| | - Yajun Lian
- Department of Neurology The First Affiliated Hospital of Zhengzhou University Henan China
| | - Tiancheng Wang
- Department of Neurology The Second Hospital of Lanzhou University Gansu China
| | - Qun Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- National Center for Clinical Medicine of Neurological Diseases Beijing China
- Collaborative Innovation Center for Brain Disorders Beijing Institute of Brain Disorders Capital Medical University Beijing China
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Herrera E, Rodríguez S, González-Nosti M. Neuropsychological follow-up of a case of encephalitis by anti-nmda receptor. Neurocase 2022; 28:96-101. [PMID: 35073821 DOI: 10.1080/13554794.2022.2032186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 10/19/2022]
Abstract
Anti-NMDA receptor encephalitis is an autoimmune disease with psychiatric and cognitive symptoms. Our aim is to describe the cognitive follow-up of a patient diagnosed with the disease for 4 years. The results revealed severe cognitive impairment at the initial evaluation. At 3 months, memory and executive function deficits prevailed. At 9 months, only a deficit in verbal memory was found. At 4 years, she presented a mild memory deficit. These results revealed a significant short-term cognitive deficit. Subsequently, executive functions, memory and verbal fluency recovered, while a mild deficit in verbal memory persisted.
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Affiliation(s)
- Elena Herrera
- Department of Psychology, Universidad de Oviedo, Oviedo, Spain
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Nguyen Thanh L, Hoang VT, Le Thu H, Nguyen PAT, Hoang DM, Ngo DV, Cao Vu H, Nguyen Thi Bich V, Heke M. Human Umbilical Cord Mesenchymal Stem Cells for Severe Neurological Sequelae due to Anti- N-Methyl-d-Aspartate Receptor Encephalitis: First Case Report. Cell Transplant 2022; 31:9636897221110876. [PMID: 35815930 PMCID: PMC9277426 DOI: 10.1177/09636897221110876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is caused by altered patient immune reactions. This study reports the first patient with severe neurologic sequelae after NMDA receptor encephalitis treated with allogeneic umbilical cord-derived mesenchymal stem/stromal cells (UC-MSCs). A 5-year-old girl was diagnosed with NMDA receptor encephalitis and treated with immunosuppressive medicaments and intravenous immunoglobulin (IVIG). Despite intensive therapy, the patient's condition worsened so that allogenic UC-MSC therapy was contemplated. The patient received three intrathecal infusions of xeno- and serum-free cultured UC-MSCs at a dose of 106 cells/kg. At baseline and after each UC-MSC administration, the patient was examined by the German Coma Recovery Scale (CRS), the Gross Motor Function Classification System (GMFCS), the Gross Motor Function Measure-88 (GMFM-88), the Manual Ability Classification System (MACS), the Modified Ashworth Scale, and the Denver II test. Before cell therapy, she was in a permanent vegetative state with diffuse cerebral atrophy. Her cognition and motor functions improved progressively after three UC-MSC infusions. At the last visit, she was capable of walking, writing, and counting numbers. Control of urinary and bowel functions was completely recovered. Cerebral atrophy was reduced on brain magnetic resonance imaging (MRI). Overall, the outcomes of this patient suggest a potential cell therapy for autoimmune encephalitis and its neurological consequences.
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Affiliation(s)
- Liem Nguyen Thanh
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec Health Care System, Hanoi, Vietnam.,College of Health Science, VinUniversity, Hanoi, Vietnam
| | - Van T Hoang
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec Health Care System, Hanoi, Vietnam
| | | | | | - Duc M Hoang
- Vinmec Research Institute of Stem Cell and Gene Technology, Vinmec Health Care System, Hanoi, Vietnam
| | | | - Hung Cao Vu
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Michael Heke
- Department of Biology, Stanford University, Stanford, CA, USA
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Yang S, Wu Y, Sun L, Ma M, Ou S, Meng Y, Meng J, Zeng C, Huang Q, Wu Y. White matter abnormalities and multivariate pattern analysis in anti-NMDA receptor encephalitis. Front Psychiatry 2022; 13:997758. [PMID: 36213924 PMCID: PMC9537694 DOI: 10.3389/fpsyt.2022.997758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/19/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study aimed to investigate white matter (WM) microstructural alterations and their relationship correlation with disease severity in anti-NMDA receptor (NMDAR) encephalitis. Multivariate pattern analysis (MVPA) was applied to discriminate between patients and healthy controls and explore potential imaging biomarkers. METHODS Thirty-two patients with anti-NMDAR encephalitis and 26 matched healthy controls underwent diffusion tensor imaging. Tract-based spatial statistics and atlas-based analysis were used to determine WM microstructural alterations between the two groups. MVPA, based on a machine-learning algorithm, was applied to classify patients and healthy controls. RESULTS Patients exhibited significantly reduced fractional anisotropy in the corpus callosum, fornix, cingulum, anterior limb of the internal capsule, and corona radiata. Moreover, mean diffusivity was increased in the anterior corona radiata and body of the corpus callosum. On the other hand, radial diffusivity was increased in the anterior limb of the internal capsule, cingulum, corpus callosum, corona radiata, and fornix. WM changes in the cingulum, fornix, and retrolenticular part of the internal capsule were correlated with disease severity. The accuracy, sensitivity, and specificity of fractional anisotropy-based classification were each 78.33%, while they were 67.71, 65.83, and 70% for radial diffusivity. CONCLUSION Widespread WM lesions were detected in anti-NMDAR encephalitis. The correlation between WM abnormalities and disease severity suggests that these alterations may serve a key role in the pathophysiological mechanisms of anti-NMDAR encephalitis. The combination of tract-based spatial statistics and MVPA may provide more specific and complementary information at the group and individual levels.
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Affiliation(s)
- Shengyu Yang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ying Wu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lanfeng Sun
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Meigang Ma
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Sijie Ou
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Youshi Meng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jie Meng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chunmei Zeng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qi Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yuan Wu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Sarmiento RJC, Diestro JDB, Antonio AKD, Prado MB, Adiao KJB, Dioquino-Maligaso CP. Neuroleptic Malignant Syndrome in a Patient With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Case Report and Review of Related Literature. Neurohospitalist 2022; 12:80-85. [PMID: 34950391 PMCID: PMC8689546 DOI: 10.1177/19418744211002978] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe but treatable disease that presents with symptoms similar to neuroleptic malignant syndrome (NMS). CASE REPORT We describe a 28-year old female who initially presented with headaches, behavioral changes, anxiety, lip tremors, and rigidity of extremities. She was prescribed with olanzapine and later manifested with neuroleptic malignant syndrome symptoms such as decrease in sensorium, muscle rigidity, hyperthermia and tachycardia. Further investigation showed presence of bilateral ovarian teratoma and anti-NMDAR antibodies in her serum and cerebrospinal fluid. Symptoms resolved after intravenous high-dose methylprednisolone, bilateral oophoro-cystectomy, and intravenous immunoglobulin administration. Overlapping pathological mechanisms of anti- NMDAR encephalitis and NMS were discussed. Ten patients with anti- NMDAR encephalitis and NMS were noted in a review of literature. Prognosis was favorable and intervention ranged from supportive to methylprednisolone and intravenous immunoglobulin administration, plasma exchange and teratoma resection. CONCLUSION Anti- NMDAR encephalitis patients are at risk for NMS due to antipsychotic intolerance and other interrelated pathophysiological mechanisms. The overlap between the signs and symptoms of anti-NMDAR encephalitis and NMS poses a diagnostic dilemma and warrants a careful investigation and management.
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Affiliation(s)
- Robert Joseph C. Sarmiento
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,Robert Joseph C. Sarmiento, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, 1000 Manila, Philippines.
| | - Jose Danilo B. Diestro
- Département de radiologie, radio-oncologie et médecine nucléaire, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Canada
| | - Athena Kate D. Antonio
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mario B. Prado
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Karen Joy B. Adiao
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Carissa Paz Dioquino-Maligaso
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,National Poison Management and Control Center, University of the Philippines, Philippine General Hospital, Manila, Philippines
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Giri YR, Parrill A, Damodar S, Fogel J, Ayed N, Syed M, Korie I, Ayyanar S, Typhair C, Hashmi S. Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis in Children and Adolescents: A Systematic Review and Quantitative Analysis of Reported Cases. J Can Acad Child Adolesc Psychiatry 2021; 30:236-248. [PMID: 34777507 PMCID: PMC8561849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 08/09/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE This pooled analysis, from a systematic review, examines anti-N-Methyl D-Aspartate Receptor (NMDAR) encephalitis presentation in children and adolescents. METHOD A comprehensive literature search from database inception through December 31, 2019, using PubMed, PsycInfo, and OVID was performed. Case reports and case series were included. Sample characteristics are described. Prodromal and presenting symptoms between partial recovery and full recovery are compared. The association between presenting symptoms and abnormal MRI, abnormal EEG, and tumor presence are determined. RESULTS The sample (n=283) had a mean age of 10.8 years with 75.3% females. The most common prodromal and presenting symptom was seizure (29.7% and 63.3%, respectively). Partial and full recovery did not differ for prodromal and presenting symptoms. Multivariate logistic regression analysis found that (1) delusion were significantly associated with higher odds and aggressive behavior was associated with lower odds for abnormal findings on magnetic resonance imaging (MRI); (2) waxing and waning of symptoms were significantly associated with higher odds for abnormal electroencephalograms (EEG), and (3) increased age and psychosis were each significantly associated with increased odds, and sleep disturbance and orofacial dyskinesia with lower odds for tumor presence. CONCLUSION Given the pattern of findings, routinely obtaining MRI and EEG should be considered for anti-NMDAR encephalitis in children and adolescents presenting with delusion and waxing and waning of symptoms, respectively. Investigation of tumors should be considered in patients with anti-NMDAR encephalitis especially when psychosis is present.
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Affiliation(s)
- Yam R Giri
- Department of Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, New York, USA
| | - Allison Parrill
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Sreedevi Damodar
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Joshua Fogel
- Department of Business Management, Brooklyn College, Brooklyn, New York, USA
| | - Nisrin Ayed
- Jordan University of Science and Technology, Irbid, Jordan
| | - Muhammad Syed
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
- St. George's University of London, Wandsworth, United Kingdom
| | - Ijendu Korie
- Henry Mayo Newhall Hospital, Valencia, California, USA
| | - Sivaranjani Ayyanar
- Department of Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, New York, USA
| | - Christopher Typhair
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Seema Hashmi
- Department of Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, New York, USA
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14
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Wang K, Wu D, Ji C, Luo B, Wang C, Chen Z. Abnormal Brain Activation During Verbal Memory Encoding in Postacute Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Brain Connect 2021; 12:660-669. [PMID: 34514848 PMCID: PMC9527060 DOI: 10.1089/brain.2021.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patients with postacute anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis are often left with permanent memory impairments. Given that NMDA receptors are essential to memory encoding, and encoding processes have been suggested to contribute to the success of memory retrieval, we investigate whether postacute anti-NMDA receptor encephalitis leads to abnormal brain activation during verbal memory encoding and its potential effects on subsequent memory retrieval performance. Methods: To address this issue, this study recruited 21 adult patients with anti-NMDA receptor encephalitis past the acute stage and 22 healthy controls (HCs). Functional magnetic resonance imaging (fMRI) data were collected when they completed an episodic memory task. Results: At the neural level, the patients showed higher brain activation than the HCs in the bilateral hippocampus/parahippocampus (HG/PHG), right superior temporal gyrus (STG), and right thalamus during memory encoding. At the behavioral level, the patients showed worse memory retrieval performance than the HCs. Importantly, greater brain activation in the left HG/PHG during memory encoding was significantly associated with worse memory retrieval performance among the patients. Conclusion: Our findings indicate that postacute anti-NMDA receptor encephalitis is likely related to altered brain activation during memory encoding. Particularly, less memory retrieval performance often observed in patients with postacute anti-NMDA receptor encephalitis may result from abnormal activation in HG during encoding. These observations may enhance our understanding of NMDA receptor dysfunction in the human brain. Impact statement Patients with anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis are often left with permanent memory impairments. In this study, brain activation during verbal memory encoding and its potential effects on subsequent memory retrieval performance are addressed using 21 adult patients with postacute anti-NMDA receptor encephalitis and 22 healthy controls. Greater brain activation in the left hippocampus/parahippocampus during memory encoding was significantly associated with worse memory retrieval performance among the patients. These observations enhance our understanding of NMDA receptor dysfunction in the human brain.
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Affiliation(s)
- Kang Wang
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dengchang Wu
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Caihong Ji
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunjie Wang
- Institute of Brain Science and Department of Physiology, School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou, China
| | - Zhongqin Chen
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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15
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Taraschenko O, Fox HS, Eldridge E, Wang W, Dowd SW, Al-Saleem F, Kattala CD, Dessain SK, Dingledine R. Monoclonal Antibodies From Anti-NMDA Receptor Encephalitis Patient as a Tool to Study Autoimmune Seizures. Front Neurosci 2021; 15:710650. [PMID: 34512245 PMCID: PMC8427020 DOI: 10.3389/fnins.2021.710650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/20/2021] [Indexed: 01/27/2023] Open
Abstract
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis manifests with precipitous cognitive decline, abnormal movements, and severe seizures that can be challenging to control with conventional anti-seizure medications. We previously demonstrated that intracerebroventricular (i.c.v.) administration of cerebrospinal fluid from affected patients, or purified NMDA receptor antibodies from encephalitis patients to mice precipitated seizures, thereby confirming that antibodies are directly pathogenic for seizures. Although different repertoires of anti-NMDA receptor antibodies could contribute to the distinct clinical manifestations in encephalitis patients, the role of specific antibodies in the expression of seizure, motor, and cognitive phenotypes remains unclear. Using three different patient-derived monoclonal antibodies with distinct epitopes within the N-terminal domain (NTD) of the NMDA receptor, we characterized the seizure burden, motor activity and anxiety-related behavior in mice. We found that continuous administration of 5F5, 2G6 or 3C11 antibodies for 2 weeks precipitated seizures, as measured with continuous EEG using cortical screw electrodes. The seizure burden was comparable in all three antibody-treated groups. The seizures were accompanied by increased hippocampal C-C chemokine ligand 2 (CCL2) mRNA expression 3 days after antibody infusion had stopped. Antibodies did not affect the motor performance or anxiety scores in mice. These findings suggest that neuronal antibodies targeting different epitopes within the NMDA receptor may result in a similar seizure phenotype.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Howard S. Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Ember Eldridge
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Wenyi Wang
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA, United States
| | - Samuel W. Dowd
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Fetweh Al-Saleem
- Lankenau Institute for Medical Research, Wynnewood, PA, United States
| | | | - Scott K. Dessain
- Lankenau Institute for Medical Research, Wynnewood, PA, United States
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA, United States
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16
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Nathoo N, Anderson D, Jirsch J. Extreme Delta Brush in Anti-NMDAR Encephalitis Correlates With Poor Functional Outcome and Death. Front Neurol 2021; 12:686521. [PMID: 34305794 PMCID: PMC8299704 DOI: 10.3389/fneur.2021.686521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/15/2021] [Indexed: 12/29/2022] Open
Abstract
Objective: To characterize EEG findings in anti-NMDAR encephalitis patients looking for the proportion of EEGs that were abnormal, presence of extreme delta brush (EDB), and to relate EEG findings to clinical outcomes (Glasgow Outcome Scale (GOS) at 6 months, need for ICU admission, and death). Methods: This retrospective cohort single center study included patients with anti-NMDAR encephalitis who had ≥1 EEGs obtained from 2014 to 2021. EEGs were retrospectively analyzed by 2 reviewers. Clinical outcomes of interest were extracted through hospital and clinic chart review. Results: Twenty-one patients with anti-NMDAR encephalitis were included. Sixty-four EEGs were analyzed. Four EEGs (6.3%) were within normal limits. Focal or generalized slowing (without EDB) was seen on 44 EEGs (68.8%). EDB was seen on 16 EEGs (25.0%) in 9 of 21 patients (42.9%). The presence of EDB was significantly associated with need for ICU admission (p = 0.02), poorer outcome at 6 months as per the GOS (p = 0.002), and with death (p=0.02). EDB was present on ≥1 EEG of every patient who died. Conclusions: The presence of EDB on EEG in anti-NMDAR encephalitis patients is associated with increased need for ICU admission, worse functional outcomes at 6 months, and risk of death.
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Affiliation(s)
- Nabeela Nathoo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dustin Anderson
- Department of Critical Care, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Jirsch
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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17
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Wu PM, Teng CK, Chou YY, Tu YF. Precocious puberty as a consequence of anti-NMDA receptor encephalitis in children. Pediatr Neonatol 2021; 62:361-368. [PMID: 33846107 DOI: 10.1016/j.pedneo.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/30/2020] [Revised: 12/20/2020] [Accepted: 03/11/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is one of the most common autoimmune encephalitis in children. Most children recovered well after anti-NMDA receptor encephalitis. However, the NMDA receptor network functions are critical for the developing brain in children. The long-term consequences in pediatric patients of anti-NMDA receptor encephalitis are very infrequently reported. METHODS This case series study retrospectively enrolled 10 children aged below 18 years old with antibody-proved anti-NMDA receptor encephalitis in a tertiary medical center from 2010 to 2019. Long-term neurological consequences of anti-NMDA receptor encephalitis in children were followed. RESULTS One boy and nine girls were enrolled with a median onset age of 3.6 years. The most common initial presentation was verbal reduction and psychiatric symptoms soon after some flu-like prodromal symptoms. Nearly all patients then developed decreased level of consciousness, mutism, seizures and orofacial-lingual dyskinesia. Autonomic instability occurred in 5 patients, particularly in pre-pubertal children. Only one adolescent patient had ovarian teratoma. All patients survived after immunotherapy and were followed for 5.8 ± 3.3 years after discharge. Four had epilepsy within 2 years after encephalitis, four had a cognitive deficit, one had mild psychiatric symptoms of hallucination, and none had residual involuntary movements. Moreover, two pre-pubertal children developed central precocious puberty about 3 years after encephalitis, and one required gonadotropin-releasing hormone agonist treatment. CONCLUSION Central precocious puberty could be a consequence of anti-NMDA receptor encephalitis in the pre-pubertal children. The pediatrician should pay attention to its occurrence at follow-up.
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Affiliation(s)
- Po-Ming Wu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Chao-Ku Teng
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Yen-Yin Chou
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Yi-Fang Tu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan.
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18
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Rakiro J, Sokhi D. Fatal Autoimmune Anti-NMDA-Receptor Encephalitis with Poor Prognostication Score in a Young Kenyan Female. Int Med Case Rep J 2021; 14:343-347. [PMID: 34079388 PMCID: PMC8164334 DOI: 10.2147/imcrj.s311071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
Auto-immune N-methyl-D-aspartate receptor encephalitis (NMDARE) is a relatively recently described cause of acute encephalopathy with very few reports from sub-Saharan Africa (SSA). We report a case of NMDARE in a young Kenyan female who was transferred to our facility with headaches, insomnia, behaviour changes and latterly pathognomonic orofacial dyskinesias. We comprehensively ruled out infectious and other inflammatory/auto-immune causes. She was diagnosed with NMDARE by positive antibody testing in serum and cerebrospinal fluid and changes on brain magnetic resonance imaging. She was immunosuppressed with high-dose steroids, intravenous immunoglobulins, plasma exchange and rituximab, and showed signs of neurological improvement clinically and radiologically. Unfortunately, she succumbed to septic shock from prolonged intensive care. This is the first report of NMDARE in an indigenous patient from the eastern SSA. The majority (>80%) of patients are either left with mild disability or make a full recovery after NMDARE, but some factors – which comprise the NMDARE One-Year Functional Status (NEOS) prognostication score – can adversely affect outcome, as was the case in our patient.
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Affiliation(s)
- Joe Rakiro
- Department of Medicine, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Dilraj Sokhi
- Department of Medicine, Aga Khan University Medical College of East Africa, Nairobi, Kenya
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Neale N, Nathan C, Lee S, Kalanuria A. Association of Autonomic Storming with Urinary Catheter Removal in NMDA Receptor Encephalitis: A Case Report. Neurohospitalist 2021; 11:45-48. [PMID: 33868556 DOI: 10.1177/1941874420932457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a case of a 47-year-old female who presented with altered mental status and was found to have severe anti-NMDA receptor encephalitis. Her intensive care unit course was complicated by paroxysmal sympathetic storming. She also had urinary retention for which a catheter was placed early in her admission, but attempts at removal were associated with worsening storming. Her average Clinical Features Scale score was 5.9 when the catheter was not in place compared to 3.6 with the catheter in place. This is the first case report to our knowledge demonstrating an association between urinary catheter removal and autonomic storming in anti-NMDA receptor encephalitis.
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Affiliation(s)
- Natalie Neale
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cody Nathan
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sok Lee
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Atul Kalanuria
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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20
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Wang D, Su S, Tan M, Wu Y, Wang S. Paroxysmal Sympathetic Hyperactivity in Severe Anti-N-Methyl-d-Aspartate Receptor Encephalitis: A Single Center Retrospective Observational Study. Front Immunol 2021; 12:665183. [PMID: 33912193 PMCID: PMC8072271 DOI: 10.3389/fimmu.2021.665183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) is a disorder with excessive sympathetic activity commonly recognized in patients with acquired brain injury. Autonomic instability is frequent in anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE). However, PSH in anti-NMDARE has gained little attention. Methods We retrospectively reviewed 24 patients diagnosed with severe anti-NMDARE in the neuro-intensive care unit (NICU) between 2014 and 2019. Patients were assessed with the PSH assessment measure (PSH-AM) scale, and categorized into “PSH+” group and “PSH-” group. The clinical characteristics, hospital mortality, and functional outcome by modified Rankin Scale (mRS) score at six months after discharge were compared between the two groups. Among patients with PSH+, the clinical features and pharmacotherapy of PSH were summarized and compared. Results Twenty-four patients were included in the study. Twelve of them (50%) were categorized as PSH+ based on PSH-AM scores. There were no significant differences in the demographic characteristic, GCS scores upon admission, incidence of status epilepticus, teratoma occurrence, hospital mortality, and 6-month mRS between PSH+ and PSH- groups. Patients with PSH+ had increased length of NICU stay, hospital stay and duration of mechanical ventilation. The most prominent clinical features of PSH in severe anti-NMDARE were tachycardia and hyperthermia, while posturing was the relatively mildest clinical feature. Propranolol and clonazepam were more commonly used than gabapentin in pharmacotherapy of PSH in severe anti-NMDARE. Conclusions The incidence of PSH in severe anti-NMDARE patients was as high as 50%. Patients with PSH demonstrated prolonged NICU stay, hospital stay and increased duration of mechanical ventilation, while no effect on hospital mortality and functional outcome. Clinicians should be aware of the distinctive characteristics and treatment options of PSH in severe anti-NMDARE.
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Affiliation(s)
- Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shuang Su
- Department of Geriatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Miaoqin Tan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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21
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Bell M, Friedman M, Matar M, Sakmar S, Wee CP, Ross P, Nagoshi M. Anesthesia for pediatric patients with anti-NMDA receptor encephalitis: A retrospective case series. Paediatr Anaesth 2021; 31:316-322. [PMID: 33369786 DOI: 10.1111/pan.14117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/20/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor encephalitis is caused by auto-antibodies that target the N-methyl-D-aspartate receptor. Autonomic instability is a hallmark of the disease. The objective of this case series is to examine how anesthesia affects pediatric patients with this disease. METHODS We performed a retrospective chart review of 28 records in 17 patients who underwent anesthesia. Our primary outcomes were hemodynamic changes during the perioperative period. Heart rate, systolic and diastolic blood pressures, respiratory rate, and oxygen saturation comprise our endpoints. A subgroup of patients, who underwent imaging with anesthesia, was then compared to controls. RESULTS In anti-N-methyl-D-aspartate receptor encephalitis cases, there were significant percent changes from baseline in heart rate; median = -14.3%, 95% CI (-19.3, -9.0), p < .01 at 30 min and -15.7%, (-21.1, -9.8), p < .01 at 60 min; in systolic blood pressure, -19.4%, (-23.7, -14.8) at 30 min, p < .01, and -14.8%, (-19.7, -9.5) at 60 min, p < .01; in diastolic blood pressure, -41.9%, (-46.9, -36.3), p < .01 at 30 min, and -37.5%, (-43.4, -30.9), p < .01 at 60 min. When compared to controls, there were no significant differences between the two groups across time of anesthesia (baseline to 60 min) in heart rate (p = .24), systolic blood pressure (p = .30), and diastolic blood pressure (p = .11). No patients experienced hemodynamic lability under anesthesia. One patient, with severe symptoms, died within 24 h of anesthesia. CONCLUSION Although pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis experienced vital sign changes with anesthesia, they were not clinically significant and they behaved similarly to controls. Disease severity may be a risk factor for perioperative complications.
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Affiliation(s)
- Marisa Bell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Megan Friedman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marla Matar
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shinny Sakmar
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Choo Phei Wee
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Makoto Nagoshi
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Taraschenko O, Fox HS, Zekeridou A, Pittock SJ, Eldridge E, Farukhuddin F, Al-Saleem F, Devi Kattala C, Dessain SK, Casale G, Willcockson G, Dingledine R. Seizures and memory impairment induced by patient-derived anti-N-methyl-D-aspartate receptor antibodies in mice are attenuated by anakinra, an interleukin-1 receptor antagonist. Epilepsia 2021; 62:671-682. [PMID: 33596332 DOI: 10.1111/epi.16838] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Neuroinflammation associated with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis may facilitate seizures. We previously showed that intraventricular administration of cerebrospinal fluid from patients with anti-NMDAR encephalitis to mice precipitates seizures, thereby confirming that antibodies are directly pathogenic. To determine whether interleukin (IL)-1-mediated inflammation exacerbates autoimmune seizures, we asked whether blocking the effects of IL-1 by anakinra, a selective IL-1 receptor antagonist, blunts antibody-induced seizures. METHODS We infused C57BL/6 mice intraventricularly with purified serum IgG from patients with anti-NMDAR encephalitis or monoclonal anti-NMDAR IgG; subdural electroencephalogram was continuously recorded. After a 6-day interval, mice received anakinra (25 mg/kg sc, twice daily) or vehicle for 5 days. Following a 4-day washout period, we performed behavioral tests to assess motor function, anxiety, and memory, followed by hippocampus tissue analysis to assess astrocytic (glial fibrillary acidic protein [GFAP]) and microglial (ionized calcium-binding adapter molecule [Iba]-1) activation. RESULTS Of 31 mice infused with purified patient NMDAR-IgG (n = 17) or monoclonal NMDAR-IgG (n = 14), 81% developed seizures. Median baseline daily seizure count during exposure to antibodies was 3.9; most seizures were electrographic. Median duration of seizures during the baseline was 82.5 s. Anakinra administration attenuated daily seizure frequency by 60% (p = .02). Anakinra reduced seizure duration; however, the effect was delayed and became apparent only after the cessation of treatment (p = .04). Anakinra improved novel object recognition in mice with antibody-induced seizures (p = .03) but did not alter other behaviors. Anakinra reduced the expression of GFAP and Iba-1 in the hippocampus of mice with seizures, indicating decreased astrocytic and microglial activation. SIGNIFICANCE Our evidence supports a role for IL-1 in the pathogenesis of seizures in anti-NMDAR encephalitis. These data are consistent with therapeutic effects of anakinra in other severe autoimmune and inflammatory seizure syndromes. Targeting inflammation via blocking IL-1 receptor-mediated signaling may be promising for developing novel treatments for refractory autoimmune seizures.
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Affiliation(s)
- Olga Taraschenko
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Howard S Fox
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anastasia Zekeridou
- Departments of Neurology, Laboratory Medicine, and Pathology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sean J Pittock
- Departments of Neurology, Laboratory Medicine, and Pathology, Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Ember Eldridge
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fnu Farukhuddin
- Department of Neurological Sciences, Division of Epilepsy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fetweh Al-Saleem
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Scott K Dessain
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - George Casale
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Gregory Willcockson
- Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Raymond Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia, USA
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23
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Yan L, Zhang S, Huang X, Tang Y, Wu J. Clinical Study of Autonomic Dysfunction in Patients With Anti-NMDA Receptor Encephalitis. Front Neurol 2021; 12:609750. [PMID: 33613429 PMCID: PMC7894204 DOI: 10.3389/fneur.2021.609750] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/20/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives: Autonomic dysfunction is a common symptom of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis; however, it has been poorly researched. The purpose of this study was to compare the clinical features, tumor occurrence, intensive care unit (ICU) admission, mechanical ventilation, imaging assessment, cerebrospinal fluid examination, disease severity, and immunotherapy in patients with anti-NMDAR encephalitis with or without autonomic dysfunction. Methods: A retrospective study of anti-NMDAR encephalitis patients diagnosed between January 2016 and April 2020 was performed at the First Affiliated Hospital of Zhengzhou University. Patients were divided into two groups according to whether they had autonomic dysfunction, and their clinical features, treatment, and prognosis were compared. Results: A total of 119 patients with anti-NMDAR encephalitis were included in this study. Seventy-three patients (61.3%) had autonomic dysfunction, while the remaining 46 (38.7%) did not. Sinus tachycardia (69.9%) was the autonomic dysfunction with the highest incidence, while the incidences of symptoms including constipation, central hypopnea, and others gradually decreased. Compared to the group without autonomic dysfunction, the prevalence of the main clinical symptoms such as epileptic seizure (P = 0.003), involuntary movement (P = 0.028), and decreased consciousness (P < 0.001) were higher in the group with autonomic dysfunction, which also more frequently presented with complications such as pulmonary infection (P < 0.001) and abnormal liver function (P = 0.001). Moreover, the rates of ICU admission (P < 0.001) and mechanical ventilation (P = 0.001), as well as the modified Rankin scale (mRS) scores at admission (P < 0.001), maximum mRS scores during the course of disease (P < 0.001), and mRS scores at discharge (P < 0.001) were higher in the patients with autonomic dysfunction than in those without. The number of patients in the autonomic dysfunction group who underwent ≥2 immunotherapies was also higher than that in the group without autonomic dysfunction (P < 0.001). Conclusion: Sinus tachycardia is the most common type of autonomic dysfunction in anti-NMDAR encephalitis. Compared to patients without autonomic dysfunction, those with autonomic dysfunction had a higher incidence of epilepsy, involuntary movements, decreased consciousness, pulmonary infections, abnormal liver function, ICU admissions, and mechanical ventilation; moreover, the severity of the disease was greater, and their prognosis worse. Therefore, such patients require intensive immunotherapy.
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Affiliation(s)
- Lulu Yan
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuang Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxue Huang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao Tang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jun Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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24
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Sun Y, Ren G, Ren J, Shan W, Han X, Lian Y, Wang T, Wang Q. The Association Between Age and Prognosis in Patients Under 45 Years of Age With Anti-NMDA Receptor Encephalitis. Front Neurol 2021; 11:612632. [PMID: 33447251 PMCID: PMC7802749 DOI: 10.3389/fneur.2020.612632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Abstract
This study aims to evaluate the association between age and prognosis in patients with anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) under the age of 45 years. A retrospective study was conducted in patients younger than 45 years diagnosed as anti-NMDARE in four hospitals in China. Age at admission was divided into four categories: <15, 15–24, 25–34, 35–45 years. Neurological prognosis was evaluated using modified Rankin Scale. Adjusted multivariable logistic regression was used to analyze the association. The multivariable-adjusted odds ratios (95% confidence interval) of prognosis in anti-NMDARE across the categories of age were as follows: in males, 1.00 (reference), 4.76 (0.39–58.76), 13.50 (0.79–230.40), and 8.81 (0.36–218.39) (P for trend = 0.171); in females, 1.00 (reference), 7.27 (0.36–146.19), 20.08 (1.09–370.39), and 54.41 (1.60–1,849.10) (P for trend = 0.01). We concluded that the increasing age was associated with a poorer prognosis of anti-NMDARE in females but not males.
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Affiliation(s)
- Yueqian Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guoping Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Xiong Han
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tiancheng Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
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25
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Ratuszny D, Skripuletz T, Wegner F, Groß M, Falk C, Jacobs R, Ruschulte H, Stangel M, Sühs KW. Case Report: Daratumumab in a Patient With Severe Refractory Anti-NMDA Receptor Encephalitis. Front Neurol 2020; 11:602102. [PMID: 33414761 PMCID: PMC7782967 DOI: 10.3389/fneur.2020.602102] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023] Open
Abstract
Anti-NMDA receptor encephalitis is the most common type of antibody mediated autoimmune encephalitis (AIE). Patients often develop neuropsychiatric symptoms and seizures, women are affected about four times more than men, and in about 50% the disease is associated with a neoplasia, especially teratomas of the ovary. We describe the case of a 20-year-old woman suffering from a severe therapy refractory course of anti-NMDA receptor encephalitis. Treatment included glucocorticoids, plasma exchange, intravenous immunoglobulins, rituximab, and bortezomib without clinical improvement. Due to a therapy refractive course 28 weeks after disease onset, the patient received 10 cycles of daratumumab. Therapy escalation was performed with the anti-CD38 monoclonal antibody daratumumab as off label treatment, based on the therapy of refractory myeloma and led to an improvement of her clinical status. She spent about 200 days on the intensive care unit, followed by several weeks on the intermediate care unit with close follow ups every 4–6 weeks afterward. During follow-up, the patient was able to resume everyday and self-care activities, reflected by the modified Rankin scale (mRS) and Barthel index. Because this disease is potentially life threatening and can lead to irreversible brain atrophy, development of further therapy strategies are of great importance. Our case describes a successful treatment for therapy refractory anti-NMDA receptor encephalitis using the anti-CD38 antibody daratumumab.
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Affiliation(s)
| | | | - Florian Wegner
- Department of Neurology, Hannover Medical School, Hanover, Germany
| | - Matthias Groß
- Clinic for Anaesthesiology and Intensive Care, Hannover Medical School, Hanover, Germany
| | - Christine Falk
- Institute of Transplant Immunology, Hannover Medical School, Hanover, Germany
| | - Roland Jacobs
- Department of Rheumatology and Clinical Immunology, Hannover Medical School, Hanover, Germany
| | | | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hanover, Germany
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26
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Huang Y, Wang Q, Zeng S, Zhang Y, Zou L, Fu X, Xu Q. Case Report: Overlapping Multiple Sclerosis With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report and Review of Literature. Front Immunol 2020; 11:595417. [PMID: 33362777 PMCID: PMC7756053 DOI: 10.3389/fimmu.2020.595417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/09/2020] [Indexed: 01/24/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder mediated by NMDAR antibodies, typically manifesting as behavioral complaints, psychosis, seizures, movement disorders, hypoventilation, and autonomic dysfunction. In recent years, the predisposing factors and pathophysiological mechanisms of anti-NMDAR encephalitis have been tried to be clarified. It has been recognized that an overlap may be observed between anti-NMDAR encephalitis and inflammatory demyelinating disease. However, anti-NMDAR encephalitis is rarely associated with multiple sclerosis. Here, we describe a Chinese female patient diagnosed with relapsing remitting multiple sclerosis who developed anti-NMDAR encephalitis. Further, we discuss the previously reported literature.
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Affiliation(s)
- Ying Huang
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Qian Wang
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Silin Zeng
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Yaqing Zhang
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Liangyu Zou
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Xuejun Fu
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Qianhui Xu
- Department of Neurology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
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27
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Wang H. Anti-NMDA Receptor Encephalitis: Efficacy of Treatment for Male Patients and miRNA Biomarker. Curr Med Chem 2020; 27:4138-4151. [PMID: 29473497 DOI: 10.2174/0929867325666180221142623] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an acute form of encephalitis. Treatments for the anti-NMDA receptor encephalitis usually include steroids, intravenous immunoglobulin, plasma exchange, plasmapheresis, rituximab, cyclophosphamide and tumor resection. OBJECTIVE We aimed to compare the efficacy of the treatments including intravenous immunoglobulin, plasma exchange, plasmapheresis, rituximab or cyclophosphamide for male anti- NMDA receptor encephalitis patients without tumor and to discuss potential biomarkers for this disease. METHOD The Fisher exact test and the contingency table analysis were used to analyze the treatment efficacy for 43 male and 76 female patients. In addition, a hierarchical tree method was adopted to analyze the difference in the treatment efficacy between male and female patients. RESULTS The p-values of testing whether the efficacy rate of plasmapheresis (or plasma exchange) for the male patient is greater than a threshold are significantly different from the pvalues for the other two treatments. In addition, the hierarchical tree method shows that the treatment strategy associating with early recovery is different for male and female patients. CONCLUSION The results revealed that the efficacy rate of plasmapheresis (or plasma exchange) is not inferior to that of intravenous immunoglobulin and rituximab (or cyclophosphamide) for male patients without tumor. In addition, B-cell attracting C-X-C motif chemokine 13 (CXCL13) and microRNA let-7b have the potential to be the treatment response biomarkers for anti-NMDA receptor encephalitis. They may not be useful prognostic biomarkers for this encephalitis unless they are not biomarkers for other autoimmune encephalitides.
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Affiliation(s)
- Hsiuying Wang
- Institute of Statistics, National Chiao Tung University, Hsinchu 30010, Taiwan
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28
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Belova AN, Grygorieva VN, Rasteryaeva MV, Ruina EA, Belova EM, Solovieva VS, Boyko AN. [Anti-NMDAR encephalitis associated with relapsing optic neuritis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:105-113. [PMID: 32678556 DOI: 10.17116/jnevro2020120061105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autoimmune encephalitis with antibodies to NMDA receptors (anti-NMDAR encephalitis), is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.
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Affiliation(s)
- A N Belova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - V N Grygorieva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E A Ruina
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E M Belova
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
| | - V S Solovieva
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
| | - A N Boyko
- Federal Center of Cerebrovascular Pathology and Stroke of Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain and Neurotechnologies, Moscow, Russia
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29
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Baqir H, Cosmo C, Benevenuto D, Morar D, Rizvi SA, Batista LM. Ictal Catatonia in Autoimmune Encephalitis. R I Med J (2013) 2020; 103:55-58. [PMID: 32236165 PMCID: PMC8154181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Huma Baqir
- University at Buffalo, Department of Psychiatry, Buffalo, NY (present affiliation)
- Rhode Island Hospital, Brown University, Providence, RI
| | - Camila Cosmo
- Rhode Island Hospital, Brown University, Providence, RI
| | - Deborah Benevenuto
- Rhode Island Hospital, Brown University, Providence, RI
- Medical College of Wisconsin, Department of Psychiatry, Milwaukee, WI (present affiliation)
| | - Doriana Morar
- Rhode Island Hospital, Brown University, Providence, RI
| | - Syed A. Rizvi
- Rhode Island Hospital, Brown University, Providence, RI
| | - Leonardo M. Batista
- Rhode Island Hospital, Brown University, Providence, RI
- Morton Hospital, Steward Medical Group, Department of Psychiatry, Taunton, MA (present affiliation)
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30
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Turnbull MT, Siegel JL, Becker TL, Stephens AJ, Lopez-Chiriboga AS, Freeman WD. Early Bortezomib Therapy for Refractory Anti-NMDA Receptor Encephalitis. Front Neurol 2020; 11:188. [PMID: 32292386 PMCID: PMC7118211 DOI: 10.3389/fneur.2020.00188] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/27/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an increasingly recognized form of immune-mediated encephalitis. Here we present a case that represents the shortest hospitalization-to-bortezomib treatment timeline (42 days), and we believe that this is reflected in the patient's outcome with complete independence within a short timeframe. Case Report: We describe a case of anti-NMDA receptor encephalitis in an 18-year-old African American female presenting with progressive, medically refractory disease. Despite two rounds of high-dose intravenous steroids, plasma exchange, immunoglobulin administration, and rituximab for B-cell depletion, the patient failed to respond by hospital day 42 and received off-label use of the proteasome inhibitor bortezomib. During the 15 days after the bortezomib administration, the patient showed dramatic neurologic recovery that allowed her transfer out of the intensive care unit. At follow-up after 1-month, the patient reported feeling normal cognitively and showed dramatic improvement in cognitive scores. Conclusion: This case and literature review provide preliminary evidence that early treatment of anti-NMDA receptor encephalitis with the proteasome inhibitor bortezomib appears safe and tolerable. However, randomized trials are needed to show the efficacy and the long-term benefit.
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Affiliation(s)
- Marion T Turnbull
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Jason L Siegel
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.,Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Tara L Becker
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Alana J Stephens
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | | | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.,Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
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31
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Belova AN, Grygorieva VN, Rasteryaeva MV, Ruina EA, Belova EM, Solovieva VS, Boyko AN. [Anti-NMDAR encephalitis associated with relapsing optic neuritis: a case report and differential diagnosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 119:137-146. [PMID: 31934999 DOI: 10.17116/jnevro201911910137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autoimmune encephalitis with antibodies to NMDA receptors, or anti-NMDAR encephalitis, is the most common form of autoimmune encephalitis. The disease is curable, however, the lack of timely therapy can lead to the disability of patients or to the death. Difficulties in the diagnosis of anti-NMDAR encephalitis are caused by the heterogeneity of its manifestations, a possible overlapping with other autoimmune diseases and insufficient awareness about this form of encephalitis. This article presents the literature review and describes the case of anti-NMDAR encephalitis associated with recurrent optic neuritis, which might be an atypical manifestation for this disease. Optic neuritis could not be explained by overlapping with multiple sclerosis or neuromyelitis optica spectrum disorders.
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Affiliation(s)
- A N Belova
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - V N Grygorieva
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - E A Ruina
- FSBEI HE 'Privolzhsky Research Medical University', Nizhny Novgorod, Russia
| | - E M Belova
- State Budgetary Healthcare Institute 'City Clinical Hospital #3', Nizhny Novgorod, Russia
| | - V S Solovieva
- State Budgetary Healthcare Institute 'City Clinical Hospital #3', Nizhny Novgorod, Russia
| | - A N Boyko
- Pirogov National Russian Scientific Medical University, Moscow, Russia; Federal Center of Cerebrovascular Pathology and Stroke, Moscow, Russia
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32
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Ozawa A, Yamazaki M, Toda Y, Ebata T, Mine S, Kimura K. [Successful palliative surgical treatment for drug-resistant epilepsy after anti-N-methyl-D-aspartate (NMDA) receptor encephalitis: Two case reports]. Rinsho Shinkeigaku 2020; 60:32-36. [PMID: 31852867 DOI: 10.5692/clinicalneurol.cn-001266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epilepsy surgery for patients with drug-resistant epilepsy after anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has been rarely reported. The present study reports two patients with anti-NMDA receptor encephalitis, who later underwent epilepsy surgery due to drug-resistant epilepsy. The patients had refractory status epilepticus in the acute phase. The cerebrospinal fluid was positive for anti-NMDA receptor antibodies. Systemic corticosteroid therapy and plasma exchange were effective. Seizure control, however, worsened over several months after discharge, and was refractory to antiepileptic drugs. They underwent palliative epilepsy surgery, and their seizure control improved. Epilepsy surgery should be considered in patients with drug-resistant epilepsy after anti-NMDA receptor encephalitis.
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Affiliation(s)
- Akiko Ozawa
- Department of Neurology, Chiba Hokusoh Hospital
| | | | - Yusuke Toda
- Department of Neurology, Chiba Hokusoh Hospital
| | | | - Seiichiro Mine
- Division of Neurosurgery, Chiba Prefectural Sawara Hospital
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33
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Wang W, Zhang L, Chi XS, He L, Zhou D, Li JM. Psychiatric Symptoms of Patients With Anti-NMDA Receptor Encephalitis. Front Neurol 2020; 10:1330. [PMID: 32038450 PMCID: PMC6993807 DOI: 10.3389/fneur.2019.01330] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Objective: We conducted this study to analyze the clinical characteristics of the psychiatric symptoms of patients with anti-NMDAR encephalitis. Methods: A retrospective study of anti-NMDAR encephalitis in China was performed. The clinical characteristics of the psychiatric symptoms, the relationship between the antibodies titers and clinical characteristics of patients with anti-NMDAR encephalitis were determined. Results: A total of 108 patients with a definitive diagnosis of anti-NMDAR encephalitis were included in this study. 103 patients (95%) developed one or several psychiatric symptoms. The comparison of the high titer group and the low titer group showed that more patients presented psychiatric symptoms as the initial symptom in the high titer group (P = 0.020), the prevalence of the symptoms such as depressive, catatonic, and central hypoventilation were also higher in the high titer group than the low titer group (P = 0.033, 0.031 and 0.006, respectively). Meanwhile, more patients received a combination treatment of IVIg and corticosteroids in the high titer group than the low titer group and patients in high titer group were prescript with anti-psychiatric drugs more often than the patients in low titer group (P = 0.026 and 0.003, respectively). Conclusions: Psychiatric symptoms are the most common clinical characteristics of patients with anti-NMDAR encephalitis. Patients with higher antibodies titers more often presented with psychiatric symptoms as the initial symptom, and showed a more severe clinical feature. Screening for the anti-NMDAR antibodies is essentially important in patients who present psychiatric symptoms with or without other neurological symptoms.
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Affiliation(s)
- Wei Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Le Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Sa Chi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Endres D, Rauer S, Kern W, Venhoff N, Maier SJ, Runge K, Süß P, Feige B, Nickel K, Heidt T, Domschke K, Egger K, Prüss H, Meyer PT, Tebartz van Elst L. Psychiatric Presentation of Anti-NMDA Receptor Encephalitis. Front Neurol 2019; 10:1086. [PMID: 31749755 PMCID: PMC6848057 DOI: 10.3389/fneur.2019.01086] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/26/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Anti-N-methyl D-aspartate (NMDA) receptor encephalitis is an autoimmune condition characterized by neuropsychiatric symptoms, including epileptic seizures, movement disorders, autonomic instability, disturbances of consciousness, paranoia, delusions, and catatonia. Ovarian teratomas and viral infections, typically Herpes simplex viruses, have previously been demonstrated to precipitate anti-NMDA receptor encephalitis, but in many cases, the trigger remains unclear. The detection of anti-NMDA receptor antibodies in cerebrospinal fluid (CSF), in combination with other CSF, electroencephalography (EEG), or magnetic resonance imaging (MRI) abnormalities, typically leads to diagnostic clarification. Case Presentation: We present the case of a 22-year-old female patient who developed an acute polymorphic psychotic episode 3 days after receiving a booster vaccination against tetanus, diphtheria, pertussis, and polio (Tdap-IPV). Her psychiatric symptoms were initially diagnosed as a primary psychiatric disorder. Her MRI, EEG, and CSF results were non-specific. Anti-NMDA receptor IgG antibodies against the GluN1 subunit were detected in her serum (with a maximum titer of 1:320), but not in her CSF. [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) showed pronounced relative hypermetabolism of her association cortices and a relative hypometabolism of the primary cortices, on the basis of which an anti-NMDA receptor encephalitis diagnosis was made, and treatment with a steroid pulse was initiated. The treatment led to fast and convincing clinical improvement with normalization of neuropsychological findings, considerable improvement of FDG-PET findings, and decreasing antibody titers. Conclusion: The patient's psychiatric symptoms were most likely caused by anti-NMDA receptor encephalitis. Her polymorphic psychotic symptoms first occurred after she had received a Tdap-IPV booster vaccination. Although the vaccination cannot have caused the initial antibody formation since IgG serum antibodies were detected only 3 days after administration of the vaccine, the vaccine may have exerted immunomodulatory effects. MRI, EEG, and CSF findings were non-specific; however, FDG-PET identified brain involvement consistent with anti-NMDA receptor encephalitis. This case shows the importance of implementing a multimodal diagnostic work-up in similar situations. The negative CSF antibody finding furthermore fits to the hypothesis that the brain may act as an immunoprecipitator for anti-NMDA receptor antibodies.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Winfried Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon J Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kimon Runge
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick Süß
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Timo Heidt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Centre for Basics in Neuromodulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Konen FF, Schwenkenbecher P, Jendretzky KF, Hümmert MW, Wegner F, Stangel M, Sühs KW, Skripuletz T. Severe Anti- N-Methyl-D-Aspartate Receptor Encephalitis Under Immunosuppression After Liver Transplantation. Front Neurol 2019; 10:987. [PMID: 31608003 PMCID: PMC6773799 DOI: 10.3389/fneur.2019.00987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/29/2019] [Indexed: 11/24/2022] Open
Abstract
Anti-NMDA receptor encephalitis is a rare and often therapy-responsive autoimmune disease that usually affects young adults and causes neuropsychiatric symptoms. Here, we describe a 69-year-old patient who developed anti-NMDA receptor encephalitis while being under adequate immunosuppressive therapy following liver transplantation. Although a broad spectrum of different immunotherapies was applied and anti-NMDA receptor antibody titers gradually decreased, the clinical course could not be affected positively. Autoimmune encephalitis after transplantation is only described in a few cases and not well-recognized. Our case adds further evidence for anti-NMDA receptor encephalitis as the cause of neuropsychiatric symptoms even under immunosuppressive therapy in a post-transplant setting.
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Affiliation(s)
| | | | | | | | - Florian Wegner
- Department of Neurology, Hannover Medical School, Hanover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hanover, Germany
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36
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Wang H. Phylogenetic Analysis to Explore the Association Between Anti-NMDA Receptor Encephalitis and Tumors Based on microRNA Biomarkers. Biomolecules 2019; 9:E572. [PMID: 31590348 DOI: 10.3390/biom9100572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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37
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Espinola-Nadurille M, Flores-Rivera J, Rivas-Alonso V, Vargas-Cañas S, Fricchione GL, Bayliss L, Martinez-Juarez IE, Hernandez-Vanegas LE, Martinez-Hernandez R, Bautista-Gomez P, Solis-Vivanco R, Perez-Esparza R, Bustamante-Gomez PA, Restrepo-Martinez M, Ramirez-Bermudez J. Catatonia in patients with anti-NMDA receptor encephalitis. Psychiatry Clin Neurosci 2019; 73:574-580. [PMID: 31115962 DOI: 10.1111/pcn.12867] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [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: 02/01/2019] [Revised: 04/16/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
AIM There is a lack of studies related to the frequency, phenomenology, and associated features of catatonic syndrome in patients with anti-NMDA receptor encephalitis (ANMDARE). This study aimed to measure the frequency of catatonia in this condition and to delineate its particular symptoms. METHODS A prospective study was done with all inpatients who fulfilled the criteria of definite ANMDARE admitted to the National Institute of Neurology and Neurosurgery of Mexico from January 2014 to September 2018. The Bush-Francis Catatonia Rating Scale and Braünig Catatonia Rating Scale were administered at admission. RESULTS Fifty-eight patients were included and catatonia was diagnosed in 41 of these patients (70.6%). Immobility, staring, mutism, and posturing were the most frequent catatonic signs. Catatonia was associated with delirium, hallucinations, psychomotor agitation, generalized electroencephalography dysfunction, and previous use of antipsychotics. Mortality was present in 10% of the total sample; it was associated with status epilepticus, and was less frequent in the catatonia group. After immunotherapy, all cases showed a complete recovery from catatonic signs. CONCLUSION This systematic assessment of catatonic syndrome shows that it is a frequent feature in patients with ANMDARE as part of a clinical pattern that includes delirium, psychomotor agitation, and hallucinations. The lack of recognition of this pattern may be a source of diagnostic and therapeutic errors, as most physicians associate catatonia with schizophrenia and affective disorders.
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Affiliation(s)
- Mariana Espinola-Nadurille
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.,Center of Neurology and Neurosurgery, Medica Sur, Mexico City, Mexico
| | - Jose Flores-Rivera
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Veronica Rivas-Alonso
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Steven Vargas-Cañas
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Gregory L Fricchione
- Intensive Care Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Leo Bayliss
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | | | | | - Ruben Martinez-Hernandez
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Paola Bautista-Gomez
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Rodolfo Solis-Vivanco
- Neuropsychology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.,School of Psychology, National Autonomous University of Mexico, Mexico City, Mexico
| | - Rodrigo Perez-Esparza
- Addiction Research Laboratory, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | | | | | - Jesus Ramirez-Bermudez
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
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38
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Kasahara H, Sato M, Nagamine S, Makioka K, Tanaka K, Ikeda Y. Temporal Changes on 123I-Iomazenil and Cerebral Blood Flow Single-photon Emission Computed Tomography in a Patient with Anti-N-methyl-D-aspartate Receptor Encephalitis. Intern Med 2019; 58:1501-1505. [PMID: 30713292 PMCID: PMC6548939 DOI: 10.2169/internalmedicine.0987-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A 45-year-old man was admitted due to tonic seizures, aphasia, disturbance of consciousness, and abnormal behavior. Because cerebral magnetic resonance imaging findings were normal and mild cerebrospinal fluid (CSF) pleocytosis was observed, autoimmune encephalitis was suspected. The presence of anti-N-methyl-D-aspartate (NMDA) receptor antibodies in the CSF was subsequently confirmed. 123I-Iomazenil and cerebral blood flow single photon emission computed tomography (SPECT) revealed an abnormal uptake in the left frontotemporal region. Multimodal immunotherapy was administered, which remarkably improved the level of consciousness. Progressive reversibility of SPECT findings with clinical improvement suggested that the disorder-related functional deficits had been caused by anti-NMDA receptor antibodies.
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Affiliation(s)
- Hiroo Kasahara
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Masayuki Sato
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Shun Nagamine
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Kouki Makioka
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
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Yang P, Li L, Xia S, Zhou B, Zhu Y, Zhou G, Tu E, Huang T, Huang H, Li F. Effect of Clozapine on Anti-N-Methyl-D-Aspartate Receptor Encephalitis With Psychiatric Symptoms: A Series of Three Cases. Front Neurosci 2019; 13:315. [PMID: 31024238 PMCID: PMC6465601 DOI: 10.3389/fnins.2019.00315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/19/2019] [Indexed: 01/29/2023] Open
Abstract
The main clinical manifestations of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis are acute or subacute seizures, cognition impairment, and psychiatric symptoms. Nowadays, the scheme of antipsychotic therapy for this disease has not been established. This study reports three cases of anti-NMDAR encephalitis with psychiatric symptoms. The anti-NMDAR antibodies in cerebrospinal fluid (CSF) and serum were positive. The psychiatric symptoms still existed after intravenous immunoglobulin (IVIG) treatment; thus, clozapine was used for antipsychotic therapy. Case 1 was a 37-year-old man who suffered from bad mood and suicide behaviors for 1 month. Hallucination and delusion still existed after IVIG treatment and hormone therapy, and the symptoms were relieved when given clozapine for 12 months. Case 2 was a 28-year-old man who was admitted to our hospital due to injuring other people and destructive behaviors for 2 days. He showed irritability, bad temper, declined cognition, and severe delusion of persecution after IVIG treatment and hormone therapy, but the psychiatric symptoms disappeared when given clozapine for 3 months. Case 3 was a 23-year-old man who suffered from headache and babbing for 7 days. Symptoms such as irritability, bad temper, babbing, and injuring other people still existed after IVIG treatment and hormone therapy, but they disappeared when given clozapine for 2 months. Therefore, we suggest that during the treatment of anti-NMDAR encephalitis with psychiatric symptoms, if the anti-NMDAR antibodies in CSF and serum were positive, and psychiatric symptoms could not be controlled after IVIG and hormone therapy, clozapine may work.
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Affiliation(s)
- Ping Yang
- Department of Psychiatry, Hunan Brain Hospital, Clinical Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Liang Li
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China
| | - Shuaishuai Xia
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China
| | - Bin Zhou
- Department of Psychiatry, Hunan Brain Hospital, Clinical Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Yong Zhu
- Department of Psychiatry, Hunan Brain Hospital, Clinical Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Gaoya Zhou
- Department of Psychiatry, Hunan Brain Hospital, Clinical Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Erwen Tu
- Department of Psychiatry, Hunan Brain Hospital, Clinical Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Tianhao Huang
- Shanghai Institute of Measurement and Testing Technology, Shanghai, China
| | - Huiyong Huang
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China
| | - Feng Li
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China.,School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
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Wang HY, Li T, Li XL, Zhang XX, Yan ZR, Xu Y. Anti-N-methyl-D-aspartate receptor encephalitis mimics neuroleptic malignant syndrome: case report and literature review. Neuropsychiatr Dis Treat 2019; 15:773-778. [PMID: 31040676 PMCID: PMC6452791 DOI: 10.2147/ndt.s195706] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 12/17/2022] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a severe autoimmune disease characterized by complicated psychiatric and neurological symptoms and a difficult diagnosis. This disorder is commonly misdiagnosed, and diagnosis is often delayed. The clinical signs can mimic other psychiatric abnormalities, such as neuroleptic malignant syndrome (NMS) that is usually caused by antipsychotic exposure. This fact raises the question of whether the symptoms common to NMS are due to anti-NMDA receptor encephalitis or established NMS. CASES PRESENTATION We describe a rare case of a 29-year-old male without psychiatric history who initially presented with a fever, altered consciousness, behavioral changes, rigidity, and elevated creatine kinase. He was initially diagnosed with NMS. NMS-like symptoms did not improve with active treatments and disappeared for a long period after discontinuing antipsychotics. The patient gradually developed a complicated disease progression, including speech impairment, mutism, and movement disorders, and symptom progression led to the final diagnosis of anti-NMDA receptor encephalitis. The related pathophysiological mechanisms, clinical features, and treatment of this disease are reviewed. CONCLUSION We highlight that the natural progress of anti-NMDA receptor encephalitis can mimic the symptoms of NMS and NMS-like features could be due to anti-NMDA receptor encephalitis upon antipsychotic exposure, and not true NMS. Clinically, the suspicion of NMS may serve as a significant alarm to suspect anti-NMDA receptor encephalitis and lead neurologists or psychiatrists to investigate such a diagnosis.
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Affiliation(s)
- Hai-Yang Wang
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Tian Li
- Department of Cardiology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China.,Department of Internal Medicine-Cardiovascular, Qilu Hospital of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Xue-Lin Li
- Department of Intensive Care Unit, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China
| | - Xiao-Xia Zhang
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Zhong-Rui Yan
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
| | - Yang Xu
- Department of Neurology, Jining No 1 People's Hospital, Jining, Shandong Province, People's Republic of China,
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Abstract
Previous studies have shown that extreme delta brush and high beta/delta power ratio on electroencephalogram are suggestive of anti- N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. Here we report 3 anti-NMDAR encephalitis patients with ictal rhythmic alpha sinusoidal waves in temporal regions, which suggested electrographic seizures in anti-NMDAR encephalitis and indicated potential for seizure occurrence in the future. Rhythmic alpha sinusoidal waves may be an electrographic feature and helpful in distinguishing anti-NMDAR encephalitis. In addition, extreme delta brush was also observed at 47-50 days after morbidity in 2 of 3 patients.
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Affiliation(s)
- Ailiang Miao
- 1 Department of Neurology, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.,2 Department of Video-Electroencephalography, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoshan Wang
- 1 Department of Neurology, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.,2 Department of Video-Electroencephalography, Nanjing Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Chourasia N, Watkins MW, Lankford JE, Kass JS, Kamdar A. An Infant Born to a Mother With Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Pediatr Neurol 2018; 79:65-68. [PMID: 29310908 DOI: 10.1016/j.pediatrneurol.2017.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 09/30/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is an autoimmune disorder that often affects women of childbearing age, and maternal-fetal transfer of anti-NMDAR antibodies during pregnancy has been documented in both symptomatic and asymptomatic women. The effects of these antibodies on the fetus, however, are incompletely understood. PATIENT DESCRIPTION This term infant exhibited depressed respiratory effort, poor feeding, and abnormal movements after birth. Magnetic resonance imaging revealed diffuse cerebral edema with ischemic and hemorrhagic injury. Her mother had experienced anti-NMDAR encephalitis secondary to an ovarian teratoma 18 months earlier. The baby's serum NMDAR antibody titer was elevated at 1:320. Intravenous immunoglobulin did not result in clinical improvement, and care was withdrawn on day of life 20. Her mother had an elevated serum NMDAR antibodies (1:80), positive CSF antibody titers, and a new ovarian teratoma. CONCLUSION Routine testing of NMDAR antibodies in pregnant women with a previous history of anti-NMDAR encephalitis may be warranted. Infants born to these mothers should be closely monitored throughout pregnancy and after birth.
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Affiliation(s)
- Nitish Chourasia
- Division of Child and Adolescent Neurology, McGovern Medical School, UTHealth, Houston, Texas.
| | - Michael W Watkins
- Division of Child and Adolescent Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Jeremy E Lankford
- Division of Child and Adolescent Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Joseph S Kass
- Division of Neurology, Baylor College of Medicine, Houston, Texas
| | - Ankur Kamdar
- Division of Pediatric Pulmonology, Allergy/Immunology and Rheumatology, McGovern Medical School, UTHealth, Houston, Texas
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Chi X, Wang W, Huang C, Wu M, Zhang L, Li J, Zhou D. Risk factors for mortality in patients with anti-NMDA receptor encephalitis. Acta Neurol Scand 2017; 136:298-304. [PMID: 28028820 DOI: 10.1111/ane.12723] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe autoimmune disorder with a mortality of 5%-7%, but few studies have focused on the predictors of death in this disease. In this study, we aim to investigate predictors and causes of death in patients with anti-NMDAR encephalitis. METHODS In this cohort study, patients with anti-NMDAR encephalitis were enrolled at the West China Hospital of Sichuan University between June 2011 and October 2015. The outcomes of patients were evaluated by long-term follow-up. Cox regression analysis was used to assess the association between potential predictors and death. RESULTS Altogether 96 patients were included in this study, and 11 died after median 24.5 (7-57) months of follow-up. The mortality of anti-NMDAR encephalitis was 11.46%. Multivariate analysis results showed that Glasgow Coma Scale (GCS) score ≤8 at admission (HR=15.917, 95% CI=1.729-146.562; P=.015), the number of complications (HR=7.772, 95% CI=1.944-31.072; P=.004), and admission to an intensive care unit (HR=70.158, 95% CI=2.395-2055.459; P=.014) were significantly associated with increased risk of mortality. Twelve patients received second-line immunotherapy, and the cohort was relatively under-treated compared with other studies. The main causes of death were severe pneumonia, multiple organ dysfunction syndrome, and refractory status epilepticus. CONCLUSION GCS score ≤8 at admission, number of complications, and admission to an intensive care unit are predictors of death. Management of complications may improve the prognosis of anti-NMDAR encephalitis.
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Affiliation(s)
- X. Chi
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - W. Wang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - C. Huang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - M. Wu
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - L. Zhang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - J. Li
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - D. Zhou
- Department of Neurology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
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44
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Abstract
We describe a case of a young lady with anti-NMDA (N-methyl-D-aspartate) receptor encephalitis, who initially presented with status epilepticus. Her seizures and orofacial dyskinesia were refractory to four anticonvulsants. She received intravenous immunoglobulin and a left ovarian tumour (an associated feature) was resected. However, her outcome was poor because of delayed treatment, autonomic dysfunction and complications of prolonged hospitalisation. This case highlights the importance of an early recognition of this rare but increasingly recognised disease.
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Affiliation(s)
- Ching Soong Khoo
- Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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45
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Abstract
Electroencephalogram (EEG) abnormalities are very common in anti- N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. Extreme delta brush (EDB) is a distinctive EEG pattern that is can be suggestive of the diagnosis; however, the etiology of the EDB remains unclear. Furthermore, there is question with regard to its ictal or interictal nature. We report a 20-year-old woman with anti-NMDAR encephalitis whose serial video-EEG monitoring was obtained at 2, 2.5, 4, and 6 months after admission. There was a long-standing EDB lasting up to several hours, with no evolution in frequency, amplitude, or morphology, and without clear association her frequent orofacial dyskinesia. Intravenous benzodiazepine administrations did not change the EDB pattern. As her clinical symptoms improved, the EDB gradually became less prominent and less frequent, with complete resolution at 6 months after admission. These findings suggest that EDB is more likely a marker of the severity of the disease in contrast to an epileptic seizure and is useful for diagnosis and monitoring of treatment response in conjunction with clinical improvement.
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Affiliation(s)
- Yanfang Shi
- 1 EEG Monitoring Unit, Neurology, Barnes Jewish Hospital, St Louis, MO, USA
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46
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Abstract
Anti- N-methyl-d-aspartate receptor (NMDAR) encephalitis has been shown to be a treatable form of autoimmune encephalitis, but there remains no standardized approach to immunotherapy. We designed an anonymous survey sent to members of the Child Neurology Society to identify the current practices among child neurologists. A total of 151 pediatric neurologists responded to the survey. With these responses we were able to highlight areas of practice uniformity, including first-line treatment with intravenous immunoglobulin and intravenous methylprednisone and initiation of disease-modifying therapy with rituximab alone. The survey also identifies existing gaps in knowledge, specifically, when to add disease-modifying therapy and how long to continue therapy. We propose that the areas of agreement can be used as a step toward establishing standard treatment guidelines and research protocols directed at evidence-based clinical trials.
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Affiliation(s)
- Ilana Kahn
- 1 Department of Neurology, Children's National Health System, NW, Washington, DC, USA
| | - Guy Helman
- 1 Department of Neurology, Children's National Health System, NW, Washington, DC, USA.,2 Children's Research Institute, NW, Washington, DC, USA
| | - Adeline Vanderver
- 1 Department of Neurology, Children's National Health System, NW, Washington, DC, USA.,2 Children's Research Institute, NW, Washington, DC, USA
| | - Elizabeth Wells
- 1 Department of Neurology, Children's National Health System, NW, Washington, DC, USA
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47
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Abstract
Anti-N-methyl-d-aspartate (Anti-NMDA) receptor encephalitis is an acute autoimmune neurological disorder. The cause of this disease is often unknown, and previous studies revealed that it might be caused by a virus, vaccine or tumor. It occurs more often in females than in males. Several cases were reported to be related to vaccination such as the H1N1 vaccine and tetanus/diphtheria/pertussis and polio vaccines. In this study, we reported an anti-NMDA receptor encephalitis case that may be caused by Japanese encephalitis vaccination. To investigate the association between anti-NMDA receptor encephalitis and vaccination, we analyzed the phylogenetic relationship of the microRNAs, which significantly regulate these vaccine viruses or bacteria, and the phylogenetic relationship of these viruses and bacteria. This reveals that anti-NMDA receptor encephalitis may be caused by Japanese encephalitis vaccination, as well as H1N1 vaccination or tetanus/diphtheria/pertussis and polio vaccinations, from the phylogenetic viewpoint.
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Affiliation(s)
- Hsiuying Wang
- Institute of Statistics, National Chiao Tung University, Hsinchu 30010, Taiwan.
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48
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Rozier M, Morita D, King M. Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Potential Mimic of Neuroleptic Malignant Syndrome. Pediatr Neurol 2016; 63:71-72. [PMID: 27590992 DOI: 10.1016/j.pediatrneurol.2016.03.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 01/24/2016] [Accepted: 03/30/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune disorder characterized by behavioral changes, dyskinesia, and autonomic instability. PATIENT DESCRIPTION We describe a 14-year-old girl who initially presented with acute behavioral changes and seizures and who over a 2-week period developed high fever, tachycardia, and elevated blood pressures. RESULTS Because she received multiple medications including anticonvulsants and a neuroleptic, our patient was initially diagnosed with neuroleptic malignant syndrome, a disorder characterized by autonomic dysfunction, hyperthermia, muscle rigidity, and mental status changes usually caused by the use of a neuroleptic agent. Further investigation, however, revealed the presence of N-methyl-D-aspartate receptor antibodies and an ovarian teratoma. Symptoms resolved after teratoma resection and intravenous immunoglobulin therapy. CONCLUSION We propose that anti-N-methyl-D-aspartate receptor encephalitis can cause a paraneoplastic syndrome mimicking neuroleptic malignant syndrome.
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Affiliation(s)
- Margaret Rozier
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Denise Morita
- Department of Pediatric Neurology, Granger Medical Clinic, Riverton, Utah
| | - Marta King
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri.
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49
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Abstract
Recently, clinicians have identified overlapping but distinguishable encephalitides, each associated with antibodies in serum and cerebrospinal fluid directed against specific cell surface proteins. The antibody targets identified to date are proteins that modulate cell physiology, synaptic transmission, and circuit function. Clinical and laboratory evidence suggests that the anti-cell surface antibodies are not simply markers of disease, but are pathogenic. Patient antibodies to N-methyl-d-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), or gamma-aminobutyric acid-A (GABAA) receptors cause a loss of cognate receptors from synapses, while recent work has shown that antibodies to GABAB receptors directly antagonize receptor activity. Despite the distinct mechanisms by which patient antibodies abrogate the function of their targets, the resulting pathophysiology leads to abnormal circuit activity and plasticity, which manifests as patient signs and symptoms. Understanding the underlying synaptic and circuit mechanisms of patient autoantibody action may enable clinicians to develop diagnostics and therapies unique to each synaptic autoimmunity subtype, thereby improving patient identification and outcomes.
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Affiliation(s)
- Ankit Jain
- Department of Neuroscience, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rita Balice-Gordon
- Department of Neuroscience, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Neuroscience and Pain Research Unit, Pfizer, Inc., Cambridge, MA, USA.
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50
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Wang W, Li JM, Hu FY, Wang R, Hong Z, He L, Zhou D. Anti-NMDA receptor encephalitis: clinical characteristics, predictors of outcome and the knowledge gap in southwest China. Eur J Neurol 2015; 23:621-9. [PMID: 26563553 DOI: 10.1111/ene.12911] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/01/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to analyse the clinical profiles and outcomes of patients with anti- N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis in China. METHODS A retrospective study of anti-NMDAR encephalitis in China was performed between June 2011 and June 2014. The clinical characteristics and predictors of poor outcome were determined. RESULTS A total of 51 patients with a definitive diagnosis of anti-NMDAR encephalitis were included in this study. Four of them were surgically confirmed to have a neoplasm. Thirty-two patients, amongst whom 24 were female, presented with psychiatric disorder as the initial symptom, whereas 14 patients, of whom nine were male, presented with seizure as the initial symptom (P = 0.011). Twenty-nine patients (56.86%) were initially misdiagnosed with psychosis, viral encephalitis or other diseases, and 58.8% of the patients experienced at least one type of complication. It typically took 3 weeks before these patients were admitted to our hospital and another 2 weeks before the correct diagnosis was made. Forty-one patients (80%) reached a good outcome; 10 patients (20%) had a poor outcome. Older age, extended hospital stay, memory deficits, decreased consciousness, central hypoventilation, complications and abnormal cerebrospinal fluid results were associated with poor outcome (P < 0.05). CONCLUSIONS Female patients more frequently initially present with psychiatric disorder but male patients more frequently initially present with seizure. Patients with anti-NMDAR encephalitis in China have a lower incidence of neoplasm. Nevertheless, this study reveals several challenges in treating anti-NMDAR encephalitis in China that may contribute to poor outcome.
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Affiliation(s)
- W Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - J-M Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - F-Y Hu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - R Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Z Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - L He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - D Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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