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(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.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case presentation</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 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.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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 (0.4<span class="elsevierStyleHsp" style=""></span>g/kg<span class="elsevierStyleHsp" style=""></span>d<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5d) and hormone shock therapy (methylprednisolone 1000<span class="elsevierStyleHsp" style=""></span>mg/d<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>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.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">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.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">This 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.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with anti-NMDAR encephalitis often have ovarian teratomas.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></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.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] ] "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" => "<p id="par0045" class="elsevierStylePara elsevierViewall">This work was supported by <span class="elsevierStyleGrantSponsor" id="gs1">Sichuan Provincial Health and Family Planning Commission</span> (grant number <span class="elsevierStyleGrantNumber" refid="gs1">17PJ088</span>).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015900000003/v1_202208200652/S238702062200345X/v1_202208200652/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015900000003/v1_202208200652/S238702062200345X/v1_202208200652/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062200345X?idApp=UINPBA00004N" ]
Journal Information
Letter to the Editor
Panic attacks as the initial symptoms of anti-NMDAR encephalitis with refractory seizures
Ataque de pánico como síntoma inicial de encefalitis anti-NMDAR con convulsiones refractarias al tratamiento
Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China