Abstract Details

Title Mycoplasma auto-immune mediated encephalitis

Topic Autoimmune Neurology

Presentation(s) Autoimmune Neurology Posters (7:00 AM-5:00 PM)

Poster/Presentation
Number 080

Objective Mycoplasma auto-immune mediated encephalitis

Background ABSTRACT

A patient in his 40s presented with acute onset fever, headache, arthralgia, ataxia, dysarthria, ophthalmoplegia, and diplopia, on a background of an erythematous skin rash, which was previously treated as SWEET syndrome. ��Physical examination further showed cerebellar syndrome, with no pyramidal signs. Blood tests showed raised inflammatory markers. Patient was initially treated for meningoencephalitis, with no change in symptoms after antibiotics and antivirals were administered. MRI revealed hyper intensity at the right pons and cerebellar peduncles, raising concerns of subacute infarct or demyelination. Lumbar puncture showed high protein of 1.15 mg/dL, and no other findings. However, when PCR was performed, mycoplasma pneumoniae was negative, however, antibodies to m. pneumoniae were positive. ��IV prednisolone 1g was initially trialled, with no obvious therapeutic response after 5 days. As antibiotics and steroids had proved ineffective, decision was made to trial IV-IG. Two courses of IV-IG were trialled on suspicion of mycoplasma auto-immune mediated encephalitis, and symptoms subsequently resolved after 5 days. MRI was repeated after neurorehabilitation, and the hyper intensity found on the previous MRI had resolved.

Design/Methods Meningoencephalitis usually presents with clinical syndrome of stiff neck, vomiting, fever, headache, and confusion, secondary to the inflammatory brain process, and can progress to more serious neurological sequelae if not treated.��(1)��It is typically caused by an infection, whether this is a virus, bacteria, fungi, parasite, or other novel agent.

A relatively rarer form of encephalitis is auto-immune encephalitis. Rasmussen encephalitis, Bechet’s disease, Hashimoto’s encephalopathy, Bickerstaff’s brainstem encephalitis, autoimmune limbic encephalitis, and Sydenham’s chorea are a few of these auto-immune encephalopathies. In recent years, more auto-immune encephalitis cases have emerged, without clear clinical guidelines for diagnosis and management.��(2)��Numerous reviews in the topic have been published recently, and provide further clarity into diagnosis and management of auto-immune encephalopathies, and various antibody tests are now included in the diagnosis process. (3)

As a general rule, auto-immune encephalitis responds best to immunosuppression and targeted reduction of inflammation, including steroid therapy. For Hashimoto’s encephalitis for example, the disease is often referred to as steroid-responsive encephalopathy associated with autoimmune thyroiditis, logically named for high remission rates with steroids for the disease.

In this report, we study an unusual case of auto-immune encephalitis, secondary to mycoplasma pneumoniae infection in a patient whose main symptom had previously been a maculopapular rash. It should be noted that previously reported cases of m. pneumoniae infections have presented with a similar rash, although typically there are more signs of systemic illness.��(4)

Results IVIG as a therapy for auto-immune encephalitis

Management of mycoplasma mediated auto-immune encephalitis remains controversial, as there is no consensus in the literature at present nor an official treatment pathway in the United Kingdom.

Management of encephalitis varies based on cause, utilizing antivirals/antibiotics as appropriate, alongside supportive treatment like anti-pyrexials, sedatives as needed, and of course steroids. Utilization of intravenous immunoglobulins is contentious. One study demonstrated that for childhood encephalitis, prognostic indicators like hospital stay, length of spams, time to regain consciousness, and resolution of neuropathic symptoms and fever improved with intravenous immunoglobulins. Another study showed that with Japanese encephalitis, there was no benefit when compared to placebo.��(7)��

Figure 4: MRI Head post ivig

IVIG is already well accepted as a treatment for Guillian-Barre at present. Bickerstaff’s brainstem encephalitis is another type of autoimmune encephalitis, which often presents very similarly to GBS.��(8)��Interestingly, our patient Fred presented like a patient with Bickerstaff’s, which is often preceded by an upper respiratory tract infection however regrettably was not tested for Anti-Gq1b. Bickerstaff’s also typically self-resolves, which was not the case with Fred.��(9)

Conclusions Conclusion

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This was an unusual case of Mycoplasma pneumoniae auto-immune mediated encephalitis in an adult patient. While the encephalitis was managed appropriately with prednisolone in accordance to guidelines, there was limited reduction in inflammation.

The usage of IVIG, a well-established treatment for Guillain Barre, chronic inflammatory demyelinating polyradiculoneuropathy, and para-protein-associated demyelinating neuropathy, has proved useful in treating autoimmune encephalitis. As clinical suspicion grew for an auto-immune cause for our patient’s presentation, IVIG seemed the most appropriate treatment. Going into the future, IVIG may require further consideration in the earlier stages of treating autoimmune encephalitis.

Authors/Disclosures
Mohamed Diyab, MD, MBBS (EAST SUSSEX HEALTHCARE NHS TRUST) PRESENTER	Dr. Diyab has nothing to disclose.

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