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Anti-N-Methyl-D-Aspartate Receptor Encephalitis After Left Cerebritis: a Case Report and Review of the Literature

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Anti-N-Methyl-D-Aspartate Receptor Encephalitis After Left Cerebritis: a Case Report and Review of the Literature DOI：10.6314/JIMT.201908_30(4).07 內科學誌 2019：30：280-285 Anti-N-methyl-D-aspartate Receptor Encephalitis after Left Cerebritis: A Case Report and Review of the Literature Kuan-Hung Lin1, and Poh-Shiow Yeh2,3 1Department of Neurology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan (Xinhua Branch), Tainan, Taiwan; 2Department of Neurology, Chi-Mei Medical Center, Tainan, Taiwan; 3Department of Neurology, Taipei Medical University, Taipei, Taiwan Abstract Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common form of acute antibody- mediated encephalitis, and is known to be associated with ovarian teratomas, especially in young women. However, there is often no clear provoked factor, particularly in children and young men. In recent studies, herpes-simplex virus encephalitis or other virus induced encephalitis have been considered as potential immu- nological triggers for acute anti-NMDA and other types of autoantibody-mediated encephalitis. The current study demonstrated a young man suffering from anti-NMDA receptor encephalitis soon after left cerebritis and increased intracranial pressure were well treated. (J Intern Med Taiwan 2019; 30: 280-285) Key Words: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, Antibody-mediated encepha- litis, Cerebritis Introduction with relapsing neurological symptoms that occurred after the treatment of confirmed herpes simplex Anti-N-methyl-D-aspartate receptor (NMDA- virus (HSV) encephalitis. It has been shown that R) antibodies are the most common cause of acute viral infection can provoke a secondary autoim- antibody-mediated encephalitis. Anti-NMDA-R mune response. Therefore, HSV encephalitis or encephalitis was first described in four women with other virus-induced encephalitis are considered to ovarian teratomas1. Over 50% of young females be a potential immunological trigger for acute auto- affected by anti-NMDA-R antibody encephalitis immune encephalitis3-5. Early diagnosis and prompt are also associated with ovarian teratomas, but anti- immunotherapy are important factors for improv- NMDA-R antibody encephalitis may occur without ing the prognosis of virus-associated anti-NMDA- a clear provocation, especially in men and children2. R encephalitis. However, early identification of the In recent years, many studies have reported that cause is not easy because infectious encephalitis and anti-NMDA-R antibodies were detected in patients immune-mediated encephalitis have similar clinical Reprint requests and correspondence：Dr. Poh-Shiow Yeh Address：Department of Neurology, Chi-Mei Medical Center, 901, Chung-Hwa Road, Yung-Kang City, Tainan, 71004, Taiwan (R.O.C.) Anti-NMDA Receptor Encephalitis after Cerebritis 281 without epileptiform discharges (Figure 3A). The The second EEG examination revealed diffuse slow first cerebrospinal fluid (CSF) analysis showed a waves over both sides of the brain (Figure 3B), but high opening pressure of >400 mm H2O and promi- a follow-up MRI performed at 10 days after admis- nent lymphocytic pleocytosis (450/ml) and normal sion showed less swelling in the left cerebral and protein (62.9 mg/dl) and glucose (57 mg/dl) levels, insular cortices. The second CSF analysis revealed and an HSV polymerase chain reaction (PCR) a normal opening pressure of 70 mm H2O and was negative. According to clinical symptoms, the improved leukocyte pleocytosis (199/ml), and HSV CSF examination and imaging findings, infective PCR was negative; the CSF cytology reported the encephalitis was diagnosed. The patient responded presence of lymphocytes and plasma cells. Although to treatments for infective encephalitis, including improvement was noted in the patient’s CSF results the osmotic agent acyclovir, ceftriaxone and prophy- and sequential brain MRIs, he began to have various lactic valproate sodium, aimed at treating increased types of seizures, including head turned to one side, intracranial pressure. His spiking fever and severe right arm fencing posture, and automatisms with headache rapidly subsided, but he still had difficulty chewing movements, tongue thrusting and licking. with his speech. He was treated for focal status epilepticus. After The patient gradually lapsed into a state of deep several antiepileptic agents were tried, including somnolence and confusion 10 days after admission. valproate, levetiracetam, topiramate, oxcarbaze- Figure 1. Precontrast magnetic resonance imaging of the brain revealed diffuse swelling in the left cerebral cortex. Figure 2. Postcontrast magnetic resonance imaging of the brain revealed prominent leptomeningeal enhancement along the left cerebral cortex. 282 K. H. Lin, and P. S. Yeh Figure 3. (A) An electroencephalogram (EEG) performed when the patient had headaches and motor aphasia revealed lateralized and continuous slow waves over the left brain without epileptiform discharges. (B) A follow-up EEG taken 10 days after admission when the patient was in a state of deep lethargy and stupor revealed diffuse slow waves over both sides of the brain. (C) A follow-up EEG taken when the patient had psychiatric symptoms and autonomic dysfunction revealed bilaterally diffuse delta waves (delta-brush like) alternating with generalized alpha-ranged rhythms and no epileptic activities. Anti-NMDA Receptor Encephalitis after Cerebritis 283 pam and clobazam, his seizures were gradually con- Discussion trolled. As his seizures subsided, several psychiatric According to a previous multicenter popula- symptoms appeared, such as agitation with his legs tion-based prospective study performed in England, stamping on the bed, shouting and involuntary oro- 42% of identified encephalitis cases have an infec- lingual-facial movements alternating with catato- tious cause, 21% result from acute immune-medi- nia. Pathological pyramidal signs developed with ated encephalitis, and most of the rest have an bilateral limb spasticity and ankle clonus. Auto- unknown cause6. Anti-NMDA-R encephalitis was nomic manifestations, including a change in heart first described in women with ovarian teratomas1,7 rate (<30 or over 140 beats per minute) and profuse and is known as the most common cause of anti- hyperhidrosis, were also recorded. Although a third body-mediated encephalitis in young people. Over MRI demonstrated reduced left cortical swelling, 50% of young females affected by anti-NMDA-R a concurrent EEG showed bilaterally diffuse delta antibody encephalitis also have ovarian teratomas; waves (delta-brush like) alternating with general- however, it often occurs without a clear cause, espe- ized alpha-ranged rhythms and no epileptic activity cially in men and children2. Symptoms can vary (Figure 3C). during the initial stage of anti-NMDA-R encepha- As the later-appearing neuropsychiatric symp- litis; however, they often consist of seizures, invol- toms were similar to the clinical presentation of untary movements and behavioral changes, such as anti-NMDA-R encephalitis, the possibility of pro- agitation, paranoia, psychosis and violent behav- voked autoimmune encephalitis following infec- iors. It should be noted that over 55% of patients tive encephalitis by an uncertain pathogen was with these neuropsychiatric symptoms have prodro- seriously considered. The family then agreed to a mal headaches, fever, upper respiratory symptoms third spinal tap. The third CSF analysis showed few or other flu-like symptoms, which may suggest an lymphocytes (5/ml), while anti-NMDA-R antibod- infection8. ies were detected. A thorough examination of the In recent years, several studies have reported whole body, including chest and abdomen computed that patients with HSV encephalitis developed a tomography scans, revealed no evidence of any relapsing neurological condition that was described malignancies. The patient responded slowly to intra- as “relapsing post-HSV”. The clinical features of venous immunoglobulin and then methylpredniso- these “relapsing post-HSV” patients changed and lone pulse therapy, his lucid consciousness periods were similar to those of anti-NMDA-R encephalitis, increased, and his psychiatric behaviors gradually although some had only parts of this syndrome3-5,9. decreased. The patient’s dysfluent speech improved The symptoms differed slightly, with frequent very slowly, and he was kept in an intensive speech abnormal movements, such as choreoathetosis and rehabilitation program after he was discharged from ballism, observed in children but with predomi- the hospital. A follow-up brain MRI performed at nantly abnormal behavior observed in adolescents 1.5 years after he was discharged showed no evi- and adults9. A retrospective analysis also reported dence of brain atrophy. He remained seizure-free that NMDA-R antibodies were detected in 13 out of with lamotrigine monotherapy and returned to a 44 patients during their course of HSV encephali- normal life; however, he did not continue with his tis10. This high association between HSV enceph- college courses. alitis and NMDA-R antibodies suggests that the appearance of NMDA-R antibodies may be second- 284 K. H. Lin, and P. S. Yeh ary to virus-induced neuronal damage. One study troubling psychotic behaviors began to subside. His also revealed that NMDA-R antibodies were iden- neurological deficits, aphasia and declined cogni- tified in 5 patients prospectively diagnosed with tion recovered gradually over the following months. relapsing post–HSV encephalitis and that antibody The lessons learned from this case are: first, synthesis started 1 to 4 weeks after HSV encepha-
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