Abstract Details

Title Post-infectious N-methyl-D-aspartate Receptor Encephalitis Antibody Associated with Coxsackie Virus Infection

Topic Autoimmune Neurology

Presentation(s) P7 - Poster Session 7 (11:45 AM-12:45 PM)

Poster/Presentation
Number 14-012

Objective To describe the first case of N-methyl-D-aspartate receptor antibody encephalitis (NMDARE) associated with Coxsackie meningoencephalitis.

Background NMDARE is the most common cause of autoimmune encephalitis. Often, no trigger for antibody production is identified. Etiologies commonly reported are oncogenic and post-infectious. The identification of the trigger impacts both treatment and prognosis.

Design/Methods Case report and Literature review. The authors searched PubMed for articles using the keywords: “N-methyl-D-aspartate", "encephalitis”, and “Coxsackie virus”.

Results A 22-year-old immunocompetent female presented with headache, agitation, and altered mental status. CSF analysis in the emergency room revealed lymphocytic pleocytosis, WBC of 43 with 78% lymphocytes. Testing revealed a positive Coxsackie A/B virus with a high serum titer. Serum autoimmune encephalitis panel, including NMDA-R antibody, was negative. This panel was not obtained in CSF. She was discharged home with supportive care. Over the following week, her mental status declined with further agitation, hyperphagia, and hypersexuality. A repeat lumbar puncture revealed normalized WBC of 2 and positive NMDA-R antibody. Continuous EEG showed non-convulsive status epilepticus. A CT of the abdomen and pelvis without evidence of teratoma. She received intravenous methylprednisolone and plasmapheresis with minor improvement. Subsequently intravenous immunoglobulin and rituximab infusion with improvement in mental status and resolution of seizure activity on EEG. She was discharged on psychiatric medications: sertraline, trazodone, and Ativan. These medications were successful without recurrence of mood disturbance but with residual memory difficulties.

Conclusions

Prolonged or worsening post-infectious encephalitis should prompt consideration of secondary autoimmune encephalitis, a treatable condition. NMDARE is increasingly recognized following HSV encephalitis. To date, no case has been documented secondary to the Coxsackie virus. Our case adds to the growing list of triggers for NMDARE and highlights the need for antibody testing for those with refractory encephalitis despite having an identified cause.

Authors/Disclosures
Sam Hooshmand, DO (Medical College of Wisconsin) PRESENTER	Dr. Hooshmand has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Genetech USA. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for TG Therapeutics . Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amgen. Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genetech USA. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for EMD Serono. Dr. Hooshmand has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for TG Therapeutics . Dr. Hooshmand has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Amgen . The institution of Dr. Hooshmand has received research support from Novartis .
Elise Johnson, MD	Dr. Johnson has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. Dr. Johnson has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Sanofi.
Ahmed Z. Obeidat, MD, PhD (Medical College of Wisconsin)	Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Alexion. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Biogen . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Bristol Myers Squibb. Dr. Obeidat has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Genentech. Dr. Obeidat has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for EMD Serono. Dr. Obeidat has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Novartis . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Sanofi/Genzyme . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Horizon pharmaceuticals . Dr. Obeidat has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Sandoz. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for TG Therapeutics. Dr. Obeidat has received personal compensation in the range of $50,000-$99,999 for serving on a Speakers Bureau for Alexion. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Bristol Myers Squibb. Dr. Obeidat has received personal compensation in the range of $100,000-$499,999 for serving on a Speakers Bureau for EMD Serono. Dr. Obeidat has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Banner life sciences . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Sanofi/genzyme. Dr. Obeidat has received personal compensation in the range of $50,000-$99,999 for serving on a Speakers Bureau for Horizon therapeutics . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Amgen. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for TG Therapeutics . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for AstraZeneca. The institution of Dr. Obeidat has received research support from NIH. The institution of Dr. Obeidat has received research support from NMSS and PCORI. Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Expert opinion and key opinion leader with MJH life sciences . Dr. Obeidat has received personal compensation in the range of $10,000-$49,999 for serving as a Faculty Speaker with CMSC. Dr. Obeidat has a non-compensated relationship as a Board member with CMSC that is relevant to AAN interests or activities. Dr. Obeidat has a non-compensated relationship as a Editorial Board Member with IJMSC that is relevant to AAN interests or activities. Dr. Obeidat has a non-compensated relationship as a Reviewer Editor with Frontiers Neurology that is relevant to AAN interests or activities. Dr. Obeidat has a non-compensated relationship as a Board of Trustee Member with National MS Society that is relevant to AAN interests or activities.
Danish Pardhan, MD	Dr. Pardhan has nothing to disclose.
Mohamed Osman, MBBS (Medical College of Wisconsin)	Dr. Osman has nothing to disclose.
Mohamed Hommeida (Medical Student-MCW)	No disclosure on file

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