Panic attacks as the initial symptoms of anti-NMDAR encephalitis with refractory seizures

Shi, Jian; Li, Qiang; Tang, Yufeng

doi:10.1016/j.medcle.2022.01.017

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(A) Diffuse ground-glass opacification (GGO) (arrows) and occasionally patchy consolidation (OP) (arrows) with a basilar predominance was seen on 19th August 2019. (B) Extensive OP and GGO (arrows) were shown after thoracoscopic lung biopsy. (C) The lesions (arrows) were significantly absorbed on 30th December 2019." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Xueren Li, Xuefen Chen, Yuhua Zhang" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Xueren" "apellidos" => "Li" ] 1 => array:2 [ "nombre" => "Xuefen" "apellidos" => "Chen" ] 2 => array:2 [ "nombre" => "Yuhua" "apellidos" => "Zhang" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0025775322001373" "doi" => "10.1016/j.medcli.2022.02.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322001373?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622003473?idApp=UINPBA00004N" "url" => "/23870206/0000015900000003/v1_202208200652/S2387020622003473/v1_202208200652/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2387020622003370" "issn" => "23870206" "doi" => "10.1016/j.medcle.2021.07.026" "estado" => "S300" "fechaPublicacion" => "2022-08-12" "aid" => "5818" "copyright" => "The Author(s)" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "pgl" "cita" => "Med Clin. 2022;159:152.e1-152.e12" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Consensus statement" "titulo" => "Clinical practice recommendations for the diagnosis and treatment of X-linked hypophosphatemia: A consensus based on the ADAPTE method" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "152.e1" "paginaFinal" => "152.e12" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones de práctica clínica para el diagnóstico y el tratamiento de la hipofosfatemia ligada al cromosoma X: un consenso basado en el método ADAPTE" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1651 "Ancho" => 2925 "Tamanyo" => 409762 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm for rickets. FGF-23: fibroblast growth factor 23; PTH: parathyroid hormone; RHAD: autosomal dominant hypophosphatemic rickets; ADHR: autosomal dominant hypophosphatemic rickets; GFR: glomerular filtration rate; TmP: maximal tubular phosphate reabsorption; XLH: X chromosome-linked hypophosphatemic rickets. Source: Translated and adapted with permission of Springer Nature Customer Service Centre GmbH: Goodbye, Advances in Therapy. González-Lamuño D<a class="elsevierStyleCrossRef" href="#bib0225">45</a>. ©Springer Healthcare Ltd., part of Springer Nature 2020." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Domingo González-Lamuño, Ana Lorente Rodríguez, María Isabel Luis Yanes, Silvia Marín-del Barrio, Guillermo Martínez Díaz-Guerra, Pilar Peris" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Domingo" "apellidos" => "González-Lamuño" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Lorente Rodríguez" ] 2 => array:2 [ "nombre" => "María Isabel" "apellidos" => "Luis Yanes" ] 3 => array:2 [ "nombre" => "Silvia" "apellidos" => "Marín-del Barrio" ] 4 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Martínez Díaz-Guerra" ] 5 => array:2 [ "nombre" => "Pilar" "apellidos" => "Peris" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775321005388" "doi" => "10.1016/j.medcli.2021.07.029" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321005388?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622003370?idApp=UINPBA00004N" "url" => "/23870206/0000015900000003/v1_202208200652/S2387020622003370/v1_202208200652/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Panic attacks as the initial symptoms of anti-NMDAR encephalitis with refractory seizures" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e15" "paginaFinal" => "e16" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jian Shi, Qiang Li, Yufeng Tang" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jian" "apellidos" => "Shi" ] 1 => array:2 [ "nombre" => "Qiang" "apellidos" => "Li" ] 2 => array:4 [ "nombre" => "Yufeng" "apellidos" => "Tang" "email" => array:1 [ 0 => "dryufeng@126.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ataque de pánico como síntoma inicial de encefalitis anti-NMDAR con convulsiones refractarias al tratamiento" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1699 "Ancho" => 2500 "Tamanyo" => 386427 ] ] "descripcion" => array:1 [ "en" => "We used the transfection cell method to determine the serum NMDAR IgG concentration of the patient. (A) The serum NMDAR IgG concentration 1:3200 (red arrow) of the patient before treatment compared with the control. (B) After immunoadsorption treatment,the concentration of NMDAR IgG decreased to 1:1000 (red arrow) compared with the control, suggesting that the patient's serum NMDAR IgG decreased significantly after treatment." ] ] ] "textoCompleto" => "Panic attack is a common type of anxiety disorder, mainly manifested as sudden nervousness, fear. Autoimmune encephalitis (AE) is an immune-mediated destructive disease. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis accounts for about 80% of AE.<a class="elsevierStyleCrossRef" href="#bib0020">1</a> The clinical manifestations of anti-NMDA encephalitis include abnormal mental behavior, seizures, memory loss, speech disorders, movement disorders, coma, and autonomic dysfunction. Currently, there is no clear cause of panic disorder, and no correlation has been established between encephalitis and panic disorder.<a class="elsevierStyleCrossRef" href="#bib0025">2</a>Case presentationA 14-year-old female, a middle-school student, was first hospitalized on June 09, 2020, at the Department of Neurology, Mianyang Central Hospital, China. The chief complaint was dizziness and numbness of limbs for 2 days.After 1 month, the patient had another panic attack, and her condition worsened, with speech disturbance, convulsions, and coma. The cerebrospinal fluid examination indicated that anti-NMDA IgG 1:1000, serum anti-NMDA IgG 1:3200 antibody titers are significantly higher than those in the cerebrospinal fluid during the onset of the disease. Following the treatment guidelines for AE, we used immunoglobulin shock therapy (0.4g/kgd×5d) and hormone shock therapy (methylprednisolone 1000mg/d×5d). The patient still presented stubborn seizures and coma. Immunoadsorption was selected as the second-line treatment. A total of three times immunoadsorption treatment was administered, and serum anti-NMDA IgG was 1:1000, and cerebrospinal fluid anti-NMDA IgG was 1:100. Consequently, the antibody titer of the former was significantly lowered than the latter (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the patient regained consciousness and recovered.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>At the 1-month follow-up after discharge, serum anti-NMDA IgG was 1:3200, i.e., a high antibody titer, but the patient had no new symptoms. Subsequently, serum NMDA IgG antibody was reduced to 1:100 at 2 months after discharge.DiscussionThis clinical case showed panic attacks as the first prodromal symptom. AE refers to a type of encephalitis mediated by autoimmunity, which can accumulate brain parenchyma and cerebral blood vessels. The pathogenesis of autoimmune diseases is mediated by antibodies detected in the serum and cerebrospinal fluid. We finally utilized immunosorbent therapy to achieve a significant effect. Therefore, it could be speculated that immunosorbent therapy has a good effect on refractory autoimmune encephalitis, but the natural course of the disease cannot be excluded.Patients with anti-NMDAR encephalitis often have ovarian teratomas.<a class="elsevierStyleCrossRef" href="#bib0030">3</a> For such paraneoplastic AE, tumor removal is a critical treatment. If the effects of first-line are poor, immunoadsorption therapy could be considered. The patient's serum was treated with immunoadsorption after 1 month, following which the titer decreased significantly (illustration 2), and the patient's condition improved, suggesting that the decrease in serum and cerebrospinal fluid NMDAR titer is related to the recovery of the disease.Anti-NMDAR encephalitis is a new autoimmune disease manifested as psychiatric symptoms or panic attacks at the initial stage. Immunoadsorption can be an alternative to refractory autoimmune encephalitis.Conflict of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case presentation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:2 [ "identificador" => "xack622220" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1699 "Ancho" => 2500 "Tamanyo" => 386427 ] ] "descripcion" => array:1 [ "en" => "We used the transfection cell method to determine the serum NMDAR IgG concentration of the patient. (A) The serum NMDAR IgG concentration 1:3200 (red arrow) of the patient before treatment compared with the control. (B) After immunoadsorption treatment,the concentration of NMDAR IgG decreased to 1:1000 (red arrow) compared with the control, suggesting that the patient's serum NMDAR IgG decreased significantly after treatment." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmunity and NMDA receptor in brain disorders: Where do we stand?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Hunter" 1 => "Z. Jamet" 2 => "L. Groc" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nbd.2020.105161" "Revista" => array:5 [ "tituloSerie" => "Neurobiol Dis" "fecha" => "2021" "volumen" => "147" "paginaInicial" => "105161" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33166697" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cycloid psychosis as a psychiatric expression of anti-NMDAR encephalitis. A systematic review of case reports accomplished with the authors’ cooperation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Giné Servén" 1 => "E. Boix Quintana" 2 => "M. Martínez Ramírez" 3 => "N. Guanyabens Buscà" 4 => "D. Muriana Batiste" 5 => "M. Guasp" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/brb3.1980" "Revista" => array:5 [ "tituloSerie" => "Brain Behav" "fecha" => "2021" "volumen" => "11" "paginaInicial" => "e01980" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33270360" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ovarian teratoma-associated anti-NMDAR encephalitis in a 12-year-old girl" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Lwin" 1 => "M. San Yi" 2 => "K. Mardiana" 3 => "S.Y. Woon" 4 => "T.M. Nwe" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med J Malaysia" "fecha" => "2020" "volumen" => "75" "paginaInicial" => "731" "paginaFinal" => "733" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33219185" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack622220" "titulo" => "Acknowledgments" "texto" => "This work was supported by Sichuan Provincial Health and Family Planning Commission (grant number 17PJ088)." 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