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AbstractAutoimmune encephalitis is a rapidly evolving area of study in pediatric populations, and functional neurological symptom disorders are under-studied in children. Differential diagnosis amo…


In observational research, a multi-center team of investigators called the “Spanish Pediatric Anti-MOG Study Group” discovered that 85% of children in a…


Leucine-rich glioma-inactivated protein 1 (LGI-1) mediated limbic encephalitis associated with syndrome of inappropriate antidiuretic hormone secretion: a case report Emily Whiles, Hareesh Joshi, Prachi Prachi, Venkaiah Kavuri, Satyanarayana V Sagi Oxford Medical Case Reports 2020, 2020 (1): omz136 Autoantibodies to leucine-rich glioma-inactivated protein 1 (LGI-1) are associated with inflammation of the limbic system. Faciobrachial dystonic seizures are pathognomonic for LGI1-antibiodies and their treatment with immunotherapy is effective in seizure control with a potential to prevent cognitive decline. We report a 57-year-old man who presented to the emergency department with recurrent seizures, visual hallucinations and severe memory impairment over a seven-week period; he reported a background of alcohol excess. Initial investigations revealed hyponatremia, indicating syndrome of inappropriate anti-diuretic hormone secretion. Magnetic resonance imaging of the brain revealed bilateral asymmetrical high-T2 and low-T1 signal in the medial temporal lobes. Serum immunofluorescence assay tested positive for LGI-1 antibody. Patient responded to treatment with levetiracetam, intravenous methylprednisolone and five plasma exchange sessions. Patient remains on a maintenance dose of prednisolone and azathioprine. It is imperative that clinicians recognize signs of autoimmune encephalitis in order to curb long-term sequelae and improve clinical outcomes. Read this article (multiple options) Discussion You are not logged in. Sign Up or Log In to join the discussion. Trending Papers Current management of supraventricular tachycardias: the 2019 ESC Guidelines. Thomas F Lüscher European Heart Journal 2020 February 1, 41 (5): 607-609 Drug treatment options for the 2019-new coronavirus (2019-nCoV). Hongzhou Lu Bioscience Trends 2020 January 28 Highlights in heart failure. Daniela Tomasoni, Marianna Adamo, Carlo Mario Lombardi, Marco Metra ESC Heart Failure 2019, 6 (6): 1105-1127 Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Scott L Weiss, Mark J Peters, Waleed Alhazzani, Michael S D Agus, Heidi R Flori, David P Inwald, Simon Nadel, Luregn J Schlapbach, Robert C Tasker, Andrew C Argent, Joe Brierley, Joseph Carcillo, Enitan D Carrol, Christopher L Carroll, Ira M Cheifetz, Karen Choong, Jeffry J Cies, Andrea T Cruz, Daniele De Luca, Akash Deep, Saul N Faust, Claudio Flauzino De Oliveira, Mark W Hall, Paul Ishimine, Etienne Javouhey, Koen F M Joosten, Poonam Joshi, Oliver Karam, Martin C J Kneyber, Joris Lemson, Graeme MacLaren, Nilesh M Mehta, Morten Hylander Møller, Christopher J L Newth, Trung C Nguyen, Akira Nishisaki, Mark E Nunnally, Margaret M Parker, Raina M Paul, Adrienne G Randolph, Suchitra Ranjit, Lewis H Romer, Halden F Scott, Lyvonne N Tume, Judy T Verger, Eric A Williams, Joshua Wolf, Hector R Wong, Jerry J Zimmerman, Niranjan Kissoon, Pierre Tissieres Pediatric Critical Care Medicine 2020, 21 (2): e52-e106


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Abstract Objective The aims of this study were (1) to describe the incidence of autoimmune encephalitis (AIE) and acute disseminated encephalomyelitis (ADEM) in children, (2) to validate the currently used clinical criteria to diagnose AIE, and (3) to describe pitfalls in the diagnosis of pediatric autoimmune (AI) and inflammatory neurologic disorders. Methods This study cohort consists of 3 patient categories: (1) children with antibody-mediated AIE (n = 21), (2) children with ADEM (n = 32), and (3) children with suspicion of an AI etiology of their neurologic symptoms (n = 60). Baseline and follow-up clinical data were used to validate the current guideline to diagnose AIE. In addition, patient files and final diagnoses were reviewed. Results One-hundred three of the 113 included patients fulfilled the criteria of possible AIE. Twenty-one children had antibody-mediated AIE, of whom 19 had anti-N-methyl-D-aspartate receptor (NMDAR), 1 had anti–α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, and 1 had anti–leucine-rich glioma-inactivated protein 1 encephalitis. Finally, 34 children had ADEM, and 2 children had Hashimoto encephalopathy. Mean incidence rates were 1.54 children/million (95% CI 0.95–2.35) for antibody-mediated AIE and 2.49 children/million (95% CI 1.73–3.48) for ADEM. Of the other 48 children, treating physicians’ diagnoses were reviewed. In 22% (n = 6) of children initially diagnosed as having an AI/inflammatory etiology (n = 27), no support for AI/inflammation was found. Conclusion Besides anti-NMDAR encephalitis and ADEM, other AIEs are rare in children. The current guideline to diagnose AIE is also useful in children. However, in children with nonspecific symptoms, it is important to review data critically, to perform complete workup, and to consult specialized neuroinflammatory centers. Glossary ADEM=acute disseminated encephalomyelitis; AE=autoimmune etiology; AI=autoimmune; AIE=autoimmune encephalitis; AMPAR=α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor; CBA=cell-based assay; CHANCE=Children’s Autoimmunity Related to Neuropsychiatric symptoms, Chorea and Epilepsy; FBDS=faciobrachial dystonic seizures; GAD65=glutamic acid decarboxylase 65; HSVE=herpes simplex virus encephalitis; IPMSSG=International Pediatric Multiple Sclerosis Study Group; ivMP=IV methylprednisolone; LGI1=leucine-rich glioma-inactivated protein 1; MOG=myelin oligodendrocyte glycoprotein; NMDA receptor=N-methyl-D-aspartate receptor; TPO=thyroid autoantibodies Autoimmune encephalitis (AIE) has expanded the already comprehensive list of pediatric neuroinflammatory disorders of the CNS. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis and acute disseminated encephalomyelitis (ADEM) are the most frequently described cause of AIE in children,1,–,4 and disease courses have been studied in detail, including treatment responses, functional recovery,1,4 and long-term neuropsychological outcome.5 Next to anti-NMDAR, other neuronal antibodies have been described only sporadically in children,6,–,8 whereas in adults, reported incidence of these antibodies has increased dramatically.9,10 This could indicate that besides anti-NMDAR encephalitis, neuronal antibodies occur less frequent in children or that these syndromes are unrecognized. In 2016, Graus et al.11 have described criteria to diagnose antibody-mediated AIE, ADEM, and other related autoimmune (AI) encephalitides, including Bickerstaff brainstem encephalitis, Hashimoto encephalopathy, and autoantibody-negative (seronegative) AIE, in adults and in children. These criteria allow physicians to start first-line immunotherapy in patients with typical limbic encephalitis or probable anti-NMDAR encephalitis before definite antibody diagnosis. As already stated by the authors, the criteria should be used with caution in children because the differential diagnosis is more widespread. This prospective, observational, cohort study describes the incidence of pediatric antibody-mediated AIE and ADEM in the Netherlands since 2015. In addition, the diagnostic criteria of Graus et al.11 are validated using data of prospectively collected cohorts of children with AIE, ADEM, and children with neurologic symptoms and suspicion of an autoimmune etiology (AE). Finally, we describe pitfalls in the diagnosis of pediatric AI and inflammatory neurologic disorders. Methods Patients This study cohort contains data of 3 patient groups, included between January 2015 and December 2018 in the Netherlands. The first group consists of all Dutch children, aged 0–18 years, diagnosed with antibody-mediated (definite) AIE. Antibodies were detected in serum and CSF, using commercial cell-based assays (CBAs; Euroimmun, Lübeck, Germany). Antibodies were confirmed with immunohistochemistry. All children were included after diagnosis and are being followed prospectively since. The second group consists of all Dutch children with ADEM diagnosed according to the International Pediatric Multiple Sclerosis Study Group (IPMSSG) criteria.12 who were prospectively included in the nationwide, multicenter PROUD kids study.13 The third group consists of children with a suspected AE of their neurologic symptoms. These children were prospectively included in the observational, multicenter, “Children’s Autoimmunity Related to Neuropsychiatric symptoms, Chorea and Epilepsy” (CHANCE) study. The CHANCE study was a multicenter study, with national accrual, but no means to be complete. Inclusion criteria were age below 18 years at symptom onset and one of the following clinical phenotypes: (1) limbic encephalitis, (2) new-onset status epilepticus, (3) acute encephalopathy, or (4) neuropsychiatric symptoms combined with symptoms of basal ganglia dysfunction. All serum samples, and if available CSF samples, were screened for neuronal antibodies using immunohistochemistry14 and CBAs (Euroimmun, Lübeck, Germany). Questionable or positive samples were tested with conformational laboratory techniques, including live hippocampal neurons,15 in-house CBAs, and ELISA. Antithyroid autoantibodies (TPO) were detected by fluorescence enzyme immunoassay on the Phadia 250 system using EliA according to the manufacturer’s instructions (Thermo Fisher Scientific, Freiburg, Germany). Data about medical history, disease course, treatment responses, and final diagnoses were collected. Data were collected from interviews with patients, from treating physicians, or were retrieved from patient files. Definitions The criteria of Graus et al.11 were used to define possible AIE, definite AI limbic encephalitis, probable anti-NMDAR encephalitis, Bickerstaff brainstem encephalitis, Hashimoto encephalopathy, and seronegative but probable AIE. The IPMSSG criteria12 were used to define ADEM. Final etiology was classified as (1) Definite AIE, including children with antibody-mediated AIE and ADEM. (2) Probable AIE, according to the diagnostic criteria.11 This category consisted of children with ADEM without follow-up MRI and of children with Hashimoto encephalopathy. (3) Possible AE/inflammatory, included children not fulfilling any of the diagnostic criteria panels, but with support for autoimmunity or inflammation. This category consisted partially of children with clinically defined acquired AE/inflammatory disorders, such as Rasmussen encephalitis or Sydenham chorea, and partially of children with MRI or CSF abnormalities pointing toward an AE/inflammatory etiology (pleocytosis, elevated protein, or oligoclonal bands in CSF, and MRI lesions in the temporal lobe), with exclusion of other causes, and not fulfilling the criteria of seronegative AIE.11 (4) Unknown etiology and no support for AE/inflammatory, including children without MRI or CSF abnormalities pointing toward and AE/inflammatory etiology. (5) Other diagnosis and no support for AE/inflammatory. R.F.N., M.J.T., and M.A.A.M.d.B. reviewed follow-up etiologies. Definite diagnoses were determined by consensus. Standard protocol approvals, registrations, and patient consents The Institutional Review Board of the Erasmus MC University Medical Center approved the study protocol (MEC- 2014-048; MEC-2005-247). Informed consent was obtained from all parents and additionally from children aged 12–17 years at inclusion. Statistics The annual incidence rate (from 2015 to 2018) was calculated with 95% CIs, assuming a Poisson distribution. Available data of the Dutch pediatric population were used (StatLine; Comparisons were performed using the χ2 test or the Kruskal-Wallis test. Data availability Any data not published in this article are available at the Erasmus MC University Medical Center. Patient-related data will be shared on request from any qualified investigator, maintaining anonymization of the individual patients. Results Patient characteristics We included 113 patients. Twenty-one patients had definite AIE (19%), including 19 (90%) children with anti-NMDAR encephalitis. Among them, 12 had an idiopathic etiology (63%), 6 children recently had herpes simplex virus encephalitis (HSVE; 32%), and 1 girl had an ovarian teratoma (5%) detected shortly after disease onset. The other 2 children with neuronal antibodies had anti–leucine-rich glioma-inactivated protein 1 (LGI1) encephalitis (n = 1; 5%) and anti–α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis (n = 1; 5%). Thirty-two children diagnosed with ADEM (28%) were included from the PROUD kids cohort. The other 60 patients (53%) were included from the CHANCE study. Incidence The annual incidence rates of antibody-mediated AIE and ADEM of 4 consecutive years (2015–2018) are shown in table 1. Mean incidence rates were 1.54 children/million (95% CI 0.95–2.35) and 2.49 children/million (95% CI 1.73–3.48) for AIE and ADEM, respectively. View inline View popup Table 1 Annual incidence of pediatric AIE and ADEM Validation of AIE criteria Of all 113 patients included, 103 (89%) fulfilled the criteria of possible AIE (figure 1). Demographical data are described in table 2. Children with AIE were more often female (p = 0.023), and children with ADEM were younger (p < 0.0001). Ten patients included in the CHANCE cohort did not fulfill the criteria and were excluded because of the absence of working memory deficits or psychiatric symptoms (n = 6) or because of the longer duration of symptoms (n = 4). These 10 children had epilepsy without additional symptoms (n = 4), psychiatric disorders (n = 3), mild encephalopathy with reversible lesion in the splenium (n = 1), Niemann-Pick disease type C (n = 1), or Rasmussen encephalitis without epilepsy (n = 1). Figure 1 Flowchart showing the validation of the diagnostic criteria of AIE aAccording to the International Pediatric Multiple Sclerosis Study Group criteria. bIn 21 of the 22 patients without new lesions on the second MRI anti–myelin oligodendrocyte glycoprotein (MOG) was tested; in 8/21, antibodies were present (38%). cIn 10 of the 12 patients who had no follow-up MRI, anti-MOG was tested, of them 40% (n = 4) tested positive. dOf whom, 8 had an idiopathic etiology, and 3 recently had herpes simplex virus encephalitis. In blue: probable diagnosis, first-line immunotherapy can be started. In green: definite diagnosis. ADEM = acute disseminated encephalomyelitis; AE = autoimmune etiology; AIE = autoimmune encephalitis; AMPAR = α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor; GQ1b = Ganglioside Q1b; LGI1 = leucine-rich glioma-inactivated protein 1; NMDAR = NMDA receptor; SN-AIE = seronegative autoimmune encephalitis. View inline View popup Table 2 Demographic data and comparisons between groups Of the 103 children shown in the flowchart, 1 child had definite limbic encephalitis according to the criteria (figure e-1, This was a 9-year old boy who presented with tonic-clonic seizures originating in the left temporal lobe, followed by refractory status epilepticus. He was treated with valproic acid, midazolam, and phenytoin. After status epilepticus, he developed faciobrachial dystonic seizures (FBDS)16 and hyperactive behavior. He was considered to have anti-LGI1 encephalitis, later confirmed in his serum and CSF. He was treated with IV methylprednisolone (ivMP). Because of ongoing FBDS, he was treated again with ivMP and additionally with mycophenolate mofetil, which led to seizure freedom and complete recovery. The brain MRI showed demyelinating features in 34 children (33%). In all these children, encephalopathy and other symptoms appeared reversible. In 22/34 children, the brain MRI was repeated, and in none of them, new lesions were visible. These children were diagnosed as having definite ADEM (22/103; 21%). In 31/34, myelin oligodendrocyte glycoprotein (MOG) antibodies were tested. Twelve of 31 (39%) ADEM children were MOG positive, 4 children had a relapsing disease course (ADEM-optic neuritis [N = 3], and multiphasic demyelinating encephalomyelitis [n = 1]). Fourteen of the 68 remaining patients fulfilled the criteria of probable anti-NMDAR encephalitis, of whom 11 had NMDAR antibodies, whereas the other 3 had no NMDAR antibodies (table 3). Of the children with anti-NDMAR encephalitis, 8 children had an idiopathic etiology and 3 children recently had HSVE. View inline View popup Table 3 Patients without NMDA receptor antibodies fulfilling the criteria “probable anti-NMDA receptor encephalitis” Nine additional patients had neuronal antibodies, without fulfilling the criteria of probable anti-NMDAR encephalitis. Eight turned out to have definite anti-NMDAR encephalitis, of which 4 with an idiopathic etiology (50%) but with less symptoms, 3 post-HSVE (38%), and 1 girl had an ovarian teratoma triggering the antibody production (13%). The other patient was a 17-year-old girl with anti–acetylcholine receptor-positive bulbar myasthenia gravis and a thymoma, which was surgically removed. She developed severe memory problems and mood changes within days, accompanied by clinical signs of polyneuropathy. Laboratory results showed AMPAR antibodies in her serum and CSF and an elevated anti-CV2 titer in serum (>12,800). She was treated with ivMP and IV immunoglobulins resolving both the encephalitis and polyneuropathy. No patient had Bickerstaff brainstem encephalitis. All remaining 48 children with possible AIE were tested for TPO antibodies. Six of 48 children had an increased anti-TPO titer, of whom 2 met the criteria for Hashimoto encephalopathy. One of the other 4 patients (table 4) had diabetes mellitus type 1 and co-occurrence of low-titer anti-glutamic acid decarboxylase 65 (anti-GAD65), considered clinically irrelevant. View inline View popup Table 4 Patients with increased anti-TPO not fulfilling the criteria of Hashimoto encephalopathy Follow-up etiology of patients with possible AIE Nine of the 46 children (20%) were diagnosed by their treating physician with seronegative or probable AIE, whereas none of these children fulfilled the criteria of seronegative AIE. Four of these 9 children had a pleocytosis in CSF, but no MRI abnormalities in the mesial temporal lobe. In the other 5 children, brain MRI and white blood cell count in CSF were normal. However, complete CSF analysis, including immunoglobulin G (IgG) index and oligoclonal bands, was not performed. Concerning follow-up etiology based on treating physicians’ diagnosis, these 46 children had (1) a possible AE/inflammatory etiology (n = 27), (2) no support for AE/inflammatory and another etiology (n = 9), and (3) no support for AIE/inflammatory and unknown etiology (n = 10). After revising the data, in 6 children (22%) initially considered as possible AE/inflammatory, no support for an AI/inflammatory etiology was found. Differential diagnosis of possible AIE In table 5, exemplary cases of the included patients with AIE and with other diagnoses are shown. These cases show overlapping features, which may suggest AIE, but also signs and symptoms pointing toward another diagnosis. View inline View popup Table 5 Mimics of autoimmune encephalitis in children27 Discussion This prospective observational cohort study shows that besides anti-NMDAR encephalitis and ADEM, the prevalence of other AI encephalitides is very low in children. Furthermore, we describe that these AI disorders show a stable incidence over the past 4 years. In addition, this study validates the criteria currently used to diagnose AIE and shows their usefulness to detect pediatric antibody-mediated AIE, ADEM, and Hashimoto encephalopathy in an early stage. In our cohort, a substantial number of children were diagnosed and treated as having an AI/inflammatory etiology of their neurologic symptoms, whereas in more than 20% of them, the support for autoimmunity or inflammation was lacking. The vast majority of children with definite AIE described in this cohort had anti-NMDAR encephalitis, whereas only 2 children had other neuronal antibodies (anti-LGI1 and anti-AMPAR). These antibodies have been described only sporadically in pediatric cases,17 next to other neuronal antibodies, including anti-gamma-aminobutyric acid B receptor,7 anti-gamma-aminobutyric acid A receptor,6 anti-glycine receptor,18 and anti-GAD65.19 The high prevalence of anti-NMDAR encephalitis in children compared with the very low prevalence of other antibodies is largely explained by epidemiologic factors. In our cohort, in more than 40% of the children with anti-NMDAR encephalitis, antibody production was triggered by HSVE or an ovarian teratoma, both occurring more in children and young adults.1,20 The other antibody-mediated AIE syndromes are not associated with these factors and are usually idiopathic or associated with malignancy, not occurring in childhood.11 No additional neuronal antibodies were identified in our prospectively collected cohort of children with possible AIE (CHANCE cohort), whereas others identified neuronal antibodies in 4%–10% of children with selected neurologic symptoms or syndromes (i.e., epilepsy21 and demyelinating disorders22). However, pathogenicity of most of the detected antibodies in these studies is unproven, including double-negative voltage-gated potassium channel antibodies (anti-voltage-gated potassium channel, without anti-LGI1 or anti-contactin-associated protein 2) and low-titer anti-GAD65.23,–,25 We describe that the current guideline to diagnose AIE is of additional value to correctly diagnose AI-related neurologic conditions in children. One of the most important panels in the current guideline is “probable anti-NMDAR encephalitis.” If children fulfill these criteria, immunotherapy can be started before definite antibody diagnosis. In our cohort, almost 70% of children with anti-NMDAR encephalitis with an idiopathic etiology could be identified by the use of these criteria, whereas 50% of post-HSVE anti-NMDAR encephalitis children fulfilled the criteria of “probable anti-NMDAR encephalitis.” As the criteria were meant to identify patients for initiation of treatment before antibody results are available, the identification of 70% of idiopathic patients is relevant and important. The criteria are less important in post-HSVE anti-NMDAR encephalitis. In most children with recent history of HSVE, deterioration of symptoms promptly leads to NMDAR antibodies testing because of increased knowledge of this syndrome.20 One-third of children with idiopathic or paraneoplastic anti-NMDAR encephalitis did not fulfill the criteria of probable anti-NMDAR encephalitis; these children had less symptoms, and most of them had milder disease courses than the ones who did fulfill the criteria. These findings emphasize the importance of also considering this disease in children with unexplained neuropsychiatric disorders without many additional signs. An important difficulty broached in this study was that in one-fifth of the children diagnosed with an AI or inflammatory etiology, no support for autoimmunity or inflammation was found. In many of these children, improvement after immunotherapy was considered as a criterion favoring autoimmunity. An unjustified conclusion, because many diseases can (temporarily) respond to immunotherapy, or the observed response may even be the natural course of the disease.26 However, there will always be a small level of uncertainty, which makes it even more important to perform complete workup in these children, MRI and CSF analysis, including IgG index and oligoclonal bands. In the diagnosis of these syndromes, it is important to look for signs and symptoms favoring autoimmunity or inflammation, but the differential diagnosis of possible AIE is broad, and other causes should also be considered, especially in children with aspecific signs. This study was limited because of the number of patients included. However, it is the first nationwide study describing annual incidence of pediatric antibody-mediated AIE. In the CHANCE cohort, coverage was well, but there was no nationwide coverage, and children may have been selected toward an AE, as samples of patients with a higher suspicion for AE are often referred to our center for antibody testing. Another limitation is that in most patients, CSF analysis was incomplete, and oligoclonal bands and IgG index were often lacking. Occasionally, this resulted in difficulties to adequately revise diagnosis. In doubt, we preferred to be cautious by diagnosing children with an AI of inflammatory disorder because of the therapeutic and prognostic implications. From this study, we can conclude that AIE seems to be recognized properly in children. The majority of children have anti-NMDAR encephalitis or ADEM whereas other AIE syndromes occur only sporadically in children. The current guideline to diagnose AIE syndromes seems to be a useful tool to detect children with an AE of neurologic symptoms. However, especially in children not fulfilling any of the current guideline panels, it is important to be critical before diagnosing them as having an AI or inflammatory etiology of their neurologic symptoms. In addition, it is essential to perform complete diagnostic workup and to consult specialized AI/inflammatory tertiary centers if in doubt. Study funding M.J.T. was supported by an Erasmus MC fellowship, has received funding from the Netherlands Organization for Scientific Research (NWO, Veni incentive), from the Dutch Epilepsy Foundation (NEF, project 14–19), and from ZonMw (Memorabel program). Disclosure M.A.A.M. de Bruijn, A.L. Bruijstens, A.E.M. Bastiaansen, A. van Sonderen, and M.W.J. Schreurs report no disclosures. P.A.E. Sillevis Smitt holds a patent for the detection of anti-DNER and received research support from Euroimmun. R.F. Neuteboom and R.D. Thijs report no disclosures. M.J. Titulaer received research funds for serving on a scientific advisory board of MedImmune LLC., and a travel grant for lecturing in India from Sun Pharma, India. M.J. Titulaer has filed a patent for methods for typing neurological disorders and cancer, and devices for use therein, and has received research funds for serving on a scientific advisory board of MedImmune LLC, for consultation at Guidepoint Global LLC, and an unrestricted research grant from Euroimmun AG. Go to for full disclosures. Acknowledgment This work is generated within the European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases. Rogier Q. Hintzen: Deceased May 15, 2019. Appendix 1 Authors Appendix 2 CHANCE study group Footnotes Go to for full disclosures. Funding information is provided at the end of the article. The Article Processing Charge was funded by Erasmus University. Received December 2, 2019. Accepted in final form January 3, 2020. Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. 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A woman who hallucinated the Mexican Cartel were hunting her was misdiagnosed with schizophrenia before doctors realised she had a rare and deadly immune disease.  Samantha Redfield, of Angels Camp, California, suddenly began experiencing strange symptoms over a two week period in October 2019. She was rushed to hospital when she suffered a seizure, and over the next few days, began to hallucinate her sisters were dead and sob uncontrollably. When brain scans and blood tests showed nothing was wrong, 30-year-old Mrs Redfield was referred to a psychiatrist with suspected schizophrenia, by which point she hadn’t slept for ten days.   But the psychiatrist said there was something more sinister going on. She told Mrs Redfield’s family to take her straight back to A&E. After taking fluid from Mrs Redfield’s spine, the doctors were able to diagnose autoimmune encephalitis, which causes the body’s immune system to attack healthy brain cells. Inflammation and swelling lead to symptoms similar to psychosis.  Mrs Redfield was kept in hospital for two weeks while having treatment which filters the blood and removes harmful antibodies. She has almost fully recovered. Speaking about her hallucinations, Mrs Redfield said: ‘The hallucinations that I do somewhat remember were thinking I lost loved ones, I remember sobbing thinking two of my sisters had died.  ‘I also remember bits and pieces of being incredibly scared that the Mexican Cartel was hunting me, that they were outside our home. I remember very little. ‘There is what I believe a good two weeks where I remember nothing. I would be extremely happy one moment and a wreck the next.  ‘I had trouble speaking, I couldn’t write or read. I was told I stayed awake for ten days straight. ‘To simply put it, my body was attacking my brain and my body was fighting for its life.’  Mrs Redfield suddenly started to experience symptoms of stiffness and numbness in her right hand in October 2019. Over two weeks, the numbness Mrs Redfield was feeling spread to her upper right lip and she struggled to feed herself with a fork without dropping it. She said: ‘I knew something was wrong, I quickly became anxious and worried. These symptoms came on quickly over a two-week period just prior to my first seizure. ‘I remember being at a restaurant with my dad and telling him to watch this – I could feel when my hand was about to seize up – I picked up the fork with food on it and before I brought it to my mouth, my hand gave away, dropping the fork and food hit the table, we weren’t sure what to think. ‘These symptoms continued to escalate and a week after the fork incident I had my seizure.  ‘We would eventually find out these symptoms on the right side of my body were caused by swelling in the left side of my brain.’  Mrs Redfield was rushed to A&E on October 25 following her first seizure, when she also broke her ankle. A doctor ordered blood tests and MRI scans, which all came back clear.  ‘To have them come back clear was honestly scary as it left us with no answers as to what had caused the seizure,’ Mrs Redfield said. ‘Unfortunately, the days following with additional MRIs, EEGs and blood work were a blur. My health quickly started to deteriorate and do not remember much or if any of these tests.’ After being discharged from the hospital and given the all clear, Mrs Redfield can’t fully remember what happened to her as her health rapidly declined. From speaking to her family and her husband, Codey, 40, Mrs Redfield knew that she started to hallucinate. She believed that her two sisters, Katie, 29, and Danielle, 20, had died and that the Mexican Cartel were hunting her and waiting outside her house. On November 5, Mrs Redfield’s family took her back to the neurologist who misdiagnosed her with schizophrenia. Mrs Redfield said: ‘My dad scheduled an appointment with a psychiatrist the very next day. ‘I’ve been told the psychiatrist said that this is not schizophrenia, she understood I was a healthy happy 29-year-old only weeks before, she knew something was wrong.  ‘She recommended my family get me to an emergency room immediately to get admitted. My parents did just that.’  Mrs Redfield was in hospital for two weeks during which time countless tests and a spinal tap diagnosed autoimmune encephalitis.  Every years there are up to 6,000 cases of encephalitis of all types in the UK, and approximately 25,000 in the US, according to Encephalitis Society.  The condition causes inflammation of the brain and can cause traumatic symptoms similar to those seen in patients with psychosis, including confusion, hallucinations or strange behaviour. Viruses are the most common cause of infectious encephalitis. Mrs Redfield was diagnosed with a rarer autoimmune type.  It’s caused by a problem with the immune system, but doctors are still baffled as to why the body behaves this way. Mrs Redfield underwent plasma treatment called plasmapheresis which finally brought her out of her psychosis-like state. She was discharged from hospital on November 22.  She said: ‘This psychiatrist is the reason we ended up admitted at UC Davis Medical Centre where my life would be saved.  ‘The doctors turned to an aggressive treatment of plasma exchanges that truly saved my life and brought me out of psychosis.  ‘They inserted a catheter near my collar bone. Every other day a specialist would come in with a machine and bottles of plasma. This machine would take my blood into the machine where it would separate my plasma from my red blood cells. ‘The machine would then mix my plasma with the fresh plasma and inject it back into my body.  ‘This was a two-hour process that happened every other day, five times. By the second or third treatment I started to come out of my state of psychosis.’ Mrs Redfield is about to undergo immunoglobulin therapy (IVIg), whereby a mixture of antibodies are injected into the blood to help the body fight disease. She will have IVIg once a month for the next six months to a year to prevent the 20 to 30 per cent chance of relapse.  In the meantime, Mrs Redfield must take it easy; she’s put her career in marketing on hold while she gets better due to her limited energy and hasn’t had a seizure since she was in hospital. Mrs Redfield is still in recovery from her terrifying ordeal but wants to spread the word and raise awareness of her condition. She said: ‘In my case, my antibodies were not working correctly, and they turned on my body and attacked the NMDA receptors in my brain.  ‘NMDA receptors are responsible for a lot of our daily activity like human interaction, our memories, judgement and so much more.  ‘Each day is better. My body allows me about four hours of energy a day so the things I do each day are limited still. ‘I can’t drive due to the seizures and with little energy am unable to work so a lot of my time is spent with friends and family or binge watching my favourite shows. I still have a long road ahead of healing and have to remind myself daily to take it easy.  ‘My new neurologist says there is a twenty to thirty per cent chance of relapse, but we are hopeful IVIG will lessen those chances.’ Mrs Redfield added: ‘I am so thankful for the ability to share my story and raise awareness through it, in hopes of saving a life – many are misdiagnosed, not treated and trapped in their own bodies and mental health hospitals. ‘Take care of yourself, be gentle with yourself, don’t apologise for something that’s out of your control. You can’t rush healing.’ For more information, visit Mrs Redfield’s Instagram.


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JOURNAL ARTICLE Autoimmune Encephalitis and Epilepsy: Evolving Definition and Clinical Spectrum Joo Hee Seo, Yun-Jin Lee, Ki Hyeong Lee, Elakkat Gireesh, Holly Skinner, Michael Westerveld Clinical and experimental pediatrics 2020 February 6 Advances in autoimmune encephalitis studies in the past 10 years have headed to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to the disorder. The disorder or syndrome has been linked to a wide variety of pathologic processes associated with the neural-specific autoantibodies targeting both intracellular and plasma membrane antigens. However, current criteria for autoimmune encephalitis are very dependent on antibody testing and response to immunotherapy, which might delay the diagnosis. This form of encephalitis can involve children with multifaceted presentation of seizures and unexpected behavioral changes. The spectrum of neuropsychiatric symptoms in children is less definitive than in adults, and the incorporation of clinical, immunological, electrophysiological and neuroradiological results is critical for a diagnostic approach. In this review, we document the most appropriate data both clinical and immunologic characteristics of the autoimmune encephalitis known so far, with the goals of assisting clinicians in the differential diagnosis and providing a promptly effective treatment. Read this article (multiple options) Discussion You are not logged in. Sign Up or Log In to join the discussion. Related Papers Autoimmune Encephalitis and Epilepsy: Evolving Definition and Clinical Spectrum. Joo Hee Seo, Yun-Jin Lee, Ki Hyeong Lee, Elakkat Gireesh, Holly Skinner, Michael Westerveld Korean Journal of Pediatrics 2019 August 16 An evolving redefinition of autoimmune encephalitis. Susanna Esposito, Nicola Principi, Paolo Calabresi, Donato Rigante Autoimmunity Reviews 2019, 18 (2): 155-163 Glutamate receptor antibodies in neurological diseases: anti-AMPA-GluR3 antibodies, anti-NMDA-NR1 antibodies, anti-NMDA-NR2A/B antibodies, anti-mGluR1 antibodies or anti-mGluR5 antibodies are present in subpopulations of patients with either: epilepsy, encephalitis, cerebellar ataxia, systemic lupus erythematosus (SLE) and neuropsychiatric SLE, Sjogren’s syndrome, schizophrenia, mania or stroke. These autoimmune anti-glutamate receptor antibodies can bind neurons in few brain regions, activate glutamate receptors, decrease glutamate receptor’s expression, impair glutamate-induced signaling and function, activate blood brain barrier endothelial cells, kill neurons, damage the brain, induce behavioral/psychiatric/cognitive abnormalities and ataxia in animal models, and can be removed or silenced in some patients by immunotherapy. Mia Levite Journal of Neural Transmission 2014, 121 (8): 1029-75 A clinical approach to diagnosis of autoimmune encephalitis. Francesc Graus, Maarten J Titulaer, Ramani Balu, Susanne Benseler, Christian G Bien, Tania Cellucci, Irene Cortese, Russell C Dale, Jeffrey M Gelfand, Michael Geschwind, Carol A Glaser, Jerome Honnorat, Romana Höftberger, Takahiro Iizuka, Sarosh R Irani, Eric Lancaster, Frank Leypoldt, Harald Prüss, Alexander Rae-Grant, Markus Reindl, Myrna R Rosenfeld, Kevin Rostásy, Albert Saiz, Arun Venkatesan, Angela Vincent, Klaus-Peter Wandinger, Patrick Waters, Josep Dalmau Lancet Neurology 2016, 15 (4): 391-404 Autoimmune epilepsy in children: case series and proposed guidelines for identification. Jehan Suleiman, Fabienne Brilot, Bethan Lang, Angela Vincent, Russell C Dale Epilepsia 2013, 54 (6): 1036-45 Autoimmune Epilepsy. Michel Toledano, Sean J Pittock Seminars in Neurology 2015, 35 (3): 245-58 Seizures and risk of epilepsy in autoimmune and other inflammatory encephalitis. Marianna Spatola, Josep Dalmau Current Opinion in Neurology 2017, 30 (3): 345-353 [Recent progress in autoimmune encephalitis and its related disorders]. Takahiro Iizuka Rinshō Shinkeigaku, Clinical Neurology 2019 August 29, 59 (8): 491-501 [Autoimmune encephalitis, clinical, radiological and immunological data]. J Aupy, N Collongues, F Blanc, C Tranchant, E Hirsch, J De Seze Revue Neurologique 2013, 169 (2): 142-53 Autoimmune encephalitis: recent updates and emerging challenges. Sudarshini Ramanathan, Shekeeb S Mohammad, Fabienne Brilot, Russell C Dale Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia 2014, 21 (5): 722-30


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