Title : Immune-mediated encephalitis with epilepsy: Case report
Abstract:
Case A: A previously healthy male with 11 years old was taken to a community hospital with parasomnia and focal motor to bilateral tonic-clonic epileptic seizures, was diagnosed with epilepsy, medicated with valproic acid, without showing clinical improvement. Days later, patient with confusion, agitation, irritability, he was diagnosed with brief psychotic disorder and discharged home. Symptoms progressed, with orofacial dyskinesias and visual hallucinations, was brought to our hospital, Brain computerized tomography (CT) and MRI were normal. VEEG lenification, acute encephalopathy. CSF showed mildly elevated lymphocytes. Anti-NMDA-R antibodies were detected in serum and CSF. Responded to immunoglobulin. He currently returned to school, with good academic performance, without neurological sequelae 5 months after his discharge.
Case B: A previously healthy, 4-years old female, treated at a health center in her community as community-acquired pneumonia, due to a history of fever and respiratory symptoms for 3 days prior to admission. While in hospital the patient presented focal to bilateral tonic-clonic epileptic seizures, became very irritable, with altered sleep patterns, aggressiveness, emotional lability and then only drowsiness and increased epileptic seizures. Hematology biometric with leukocytosis, EEG slowing (DeltaTheta). Normal skull CT. CSF (Wbc: 2 mm2, lymphocytes 100%, proteins 21mg/dl glucose 75 mg/dl). Negative meningoencephalitis panel. TORCHES, herpes +. Antibody NMDAr positive. Medication: Oxcarbamazepine and neuroleptic. Treated with immunoglobulin, (IVIG, 2 g/kg) improvement in neurological status.
Case C: A preschool 3 years old male, healthy with sensation of cramps in the right upper limb, subsequent ipsilateral hemiparesis mentioned by the mother, Neurologic examination was normal. He developed progressive confusion, agitation, broad-based gait. Brain CT and MRI were normal. CSF was sent for anti-NMDA-R antibodies. Empiric high-dose corticosteroids were started to treat possible steroid-responsive encephalopathy. A course of IVIG (2 g/kg divided over 5 days) after steroids. Anti-NMDA-R antibodies were confirmed in the CSF. VEEG lenification, acute encephalopathy. Good response to treatment, currently without neurological affectation.
Audience Take Away notes:
- A relatively recent pathology such as NdFeB encephalitis requires clinical cases in pediatrics, a population where the clinical manifestations can be different depending on the age range and each patient
- The importance of making the diagnosis and starting treatment empirically in most cases can make a difference for the patient, avoiding neurological sequelae that can affect their quality of life
- Evaluation of neurodevelopmental stages in pediatric patients, depending on their age, what skills they have achieved and whether the pathology has produced changes during and after diagnosis and treatment
- Psychiatric clinical manifestations can cause an erroneous diagnosis, so encephalitis must be considered in patients with acute psychiatric clinical manifestations
- At the beginning of the clinical manifestations, the patient may present generalized signs and symptoms, which could be confused with common pathologies in pediatrics, usually of viral origin
