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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1454-1455

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Are we over Treating?


1 Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Consultant Pediatric Neurologist, Chaitanya Hospital, Chandigarh, India
3 Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission04-May-2018
Date of Decision23-Mar-2020
Date of Acceptance11-Jun-2020
Date of Web Publication30-Oct-2021

Correspondence Address:
Lokesh Saini
Pediatric Neurology and Neurodevelopment Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329580

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How to cite this article:
Sharawat IK, Jain MC, Agarwal AK, Saini L. Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Are we over Treating?. Neurol India 2021;69:1454-5

How to cite this URL:
Sharawat IK, Jain MC, Agarwal AK, Saini L. Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Are we over Treating?. Neurol India [serial online] 2021 [cited 2021 Nov 30];69:1454-5. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1454/329580




Sir,

A previously healthy 11-year-old boy presented with the complaints of low-grade, intermittent fever associated with a headache and myalgia followed by acute onset behavioral change after 34 days of onset of fever. This was marked with being in the dream-like state, delusional thinking, irritability, depression. There was no history of any drug, toxin, and environmental exposure. He was diagnosed as a case of acute neuropsychiatric disorder and was investigated. His thyroid profile, anti-TPO antibody, serum ceruloplasmin, tandem mass spectrometry, urinary organic acid profile, electroencephalogram, and magnetic resonance imaging of the brain was normal. His cerebrospinal fluid (CSF) was negative for the common viral pathogens and a paraneoplastic workup was negative too. His serum anti-NMDA antibodies were positive, which was later confirmed with CSF anti-NMDA positivity, however, titers in CSF showed very weak positivity. His parents claimed a waning phase of symptoms at the time of admission with a gradual return to normal activities, by the time CSF report is available.

A diagnosis of anti-NMDA receptor-mediated encephalitis was made. His USG abdomen was normal. As he was having a spontaneous resolution of symptoms, no active intervention was done. The parents were advised for regular follow up, but no relapse was reported during the last 12 months.

Anti-NMDAR encephalitis develops in several stages of illness and recovery. About 70% of patients have been reported to have prodromal symptoms consisting of a headache, fever, nausea, vomiting, diarrhea, or upper respiratory tract symptoms.[1] This is followed by the onset of psychiatric symptoms including anxiety, insomnia, fear, delusions, mania, paranoia, depression, agitative behavior, etc., In young children, the behavioral change can be challenging to diagnose as they often present with irritability, hyperactivity or temper tantrums, and not as frank psychosis. This may be followed by alterations of speech, insomnia, seizures, movement disorder, autonomic disturbances.[2],[3],[4] Kayser et al. have reported earlier patients of anti-NMDA encephalitis with isolated psychiatric symptoms either as the initial episode of disease or as relapse. Predominant symptoms in their case series included delusional thinking, mood disturbances, and aggression.[5]

Spontaneous recovery has been reported in a few cases of anti NMDAR encephalitis. Evoli et al.[6] found that apart from a mild semantic fluency impairment, their patient fully recovered at 42 months follow-up and concluded that this might be a self-limiting condition. Their patient, in this case, had also not reached the late, severe stage of illness. Iizuka et al.[7] report that four Japanese women with the condition showed complete physical and cognitive recovery over three or more years, though patients had indeed received treatment in the form of antiviral medication, corticosteroids, immunotherapy, and antiepilepsy therapies during their illness. Mclvor et al.[8] reported an untreated patient whose results of testing at 30 months post-discharge revealed significant improvements in immediate and delayed memory index performances. Considering the mechanism of spontaneous recovery is interesting. Researchers have questioned why some people recover well from the condition. Iizuka et al.[7] concluded that the condition results in functional rather than structural neuronal damage and therefore recovery is possible. They further suggest that improvement could be related to pharmacological effects, synaptic plasticity, or brain remodeling. Some researchers have also indicated that brain atrophy after anti-NMDAR encephalitis can be reversible.[7],[9] Further research would help us to develop a scoring system where conservative management can be possibly done for mild cases and costly therapies with significant potential long term adverse effects can be avoided.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol 2011;10:63-74.  Back to cited text no. 1
    
2.
Florance-Ryan N, Dalmau J. Update on anti-N-methyl-D-aspartate receptor encephalitis in children and adolescents: Curr Opin Pediatr 2010;6:739-44.  Back to cited text no. 2
    
3.
Jain P, Whitney R, Go C. Extreme delta brushes in a 14-year old girl with anti-NMDAR encephalitis. Neurol India 2018;66:536-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kamble N, Netravathi M, Saini J, Mahadevan A, Yadav R, Nalini A, et al. Clinical and imaging characteristics of 16 patients with autoimmune neuronal synaptic encephalitis. Neurol India 2015;63:687-96.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J. Frequency and characteristics of isolated psychiatric episodes in Anti–N-Methyl-D-Aspartate receptor encephalitis. JAMA Neurol 2013;70:1133-9.  Back to cited text no. 5
    
6.
Evoli A, Spinelli P, Frisullo G, Alboini PE, Servidei S, Marra C. Spontaneous recovery from anti-NMDAR encephalitis. J Neurol 2012;259:1964-6.  Back to cited text no. 6
    
7.
Iizuka T, Yoshii S, Kan S, Hamada J, Dalmau J, Sakai F, et al. Reversible brain atrophy in anti-NMDA receptor encephalitis: Along-term observational study. J Neurol 2010;257:1686-91.  Back to cited text no. 7
    
8.
McIvor K, Moore P. Spontaneous recovery of memory functions in an untreated case of anti NMDAR encephalitis – Areason to maintain hope. Clin Neuropsychol 2017;31:289-300.  Back to cited text no. 8
    
9.
Taguchi Y, Takashima S, Nukui T, Tanaka K. Reversible“brain atrophy” in anti-NMDA receptor encephalitis. Intern Med 2011;50:2697.  Back to cited text no. 9
    




 

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