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Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.
Am J Respir Crit Care Med. 2017 02 15; 195(4):491-499.AJ

Abstract

RATIONALE

Encephalitis caused by anti-N-methyl-d-aspartate receptor (NMDAR) antibodies is the leading cause of immune-mediated encephalitis. There are limited data on intensive care unit (ICU) management of these patients.

OBJECTIVES

To identify prognostic factors of good neurologic outcome in patients admitted to an ICU with anti-NMDAR encephalitis.

METHODS

This was an observational multicenter study of all consecutive adult patients diagnosed with anti-NMDAR encephalitis at the French National Reference Centre, admitted to an ICU between 2008 and 2014. The primary outcome was a good neurologic outcome at 6 months after ICU admission, defined by a modified Rankin Scale score of 0-2.

MEASUREMENTS AND MAIN RESULTS

Seventy-seven patients were included from 52 ICUs. First-line immunotherapy consisted of steroids (n = 61/74; 82%), intravenous immunoglobulins (n = 71/74; 96%), and plasmapheresis (n = 17/74; 23%). Forty-five (61%) patients received second-line immunotherapy (cyclophosphamide, rituximab, or both). At 6 months, 57% of patients had a good neurologic outcome. Independent factors of good neurologic outcome were early (≤8 d after ICU admission) immunotherapy (odds ratio, 16.16; 95% confidence interval, 3.32-78.64; for combined first-line immunotherapy with steroids and intravenous immunoglobulins vs. late immunotherapy), and a low white blood cell count on the first cerebrospinal examination (odds ratio, 9.83 for <5 vs. >50 cells/mm3; 95% confidence interval, 1.07-90.65). Presence of nonneurologic organ failures at ICU admission and occurrence of status epilepticus during ICU stay were not associated with neurologic outcome.

CONCLUSIONS

The prognosis of adult patients with anti-NMDAR encephalitis requiring intensive care is good, especially when immunotherapy is initiated early, advocating for prompt diagnosis and early aggressive treatment.

Authors+Show Affiliations

1 Polyvalent Intensive Care Unit, Centre Hospitalier de Saint-Denis, Saint-Denis, France.2 Neurologic Intensive Care Unit, Hôpital Pitié-Salpêtrière.3 Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, France.4 Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nancy, Nancy, France.5 Neurologic Intensive Care Unit, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, Hospices Civiles de Lyon, Lyon, France.6 Department of Medical Intensive Care and Hyperbaric Medicine, Centre Hospitalier Universitaire d'Angers, Angers, France.7 Medical Intensive Care Unit, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France.8 Medical Intensive Care Unit, Hôpital Universitaire Albert Michallon, Grenoble, France.9 Polyvalent Intensive Care Unit, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Poissy, France.10 Medical Intensive Care Unit, Groupement Hospitalier Edouard Herriot, Hospices Civiles de Lyon, Lyon, France.11 Neurologic Intensive Care Unit, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France.12 Medical Intensive Care Unit, Hôpital de la Cavale Blanche, Centre Hospitalier Universitaire Régional de Brest, Brest, France.13 Medical Intensive Care Unit, Hôpital Saint-Antoine.14 Unité Mixte de Recherche (UMR) 1137, Infection Antimicrobials Modelling Evolution Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, Institut National de la Santé et de la Recherche Médicale (INSERM), and.15 French National Reference Centre for Paraneoplastic Neurologic Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; and.15 French National Reference Centre for Paraneoplastic Neurologic Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; and.16 Medical and Infectious Diseases Intensive Care Unit, Hôpital Bichat-Claude-Bernard, and.17 Polyvalent Intensive Care Unit, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Paris, France.16 Medical and Infectious Diseases Intensive Care Unit, Hôpital Bichat-Claude-Bernard, and. 14 Unité Mixte de Recherche (UMR) 1137, Infection Antimicrobials Modelling Evolution Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, Institut National de la Santé et de la Recherche Médicale (INSERM), and.15 French National Reference Centre for Paraneoplastic Neurologic Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; and. 18 Institut NeuroMyoGene, INSERM U1217/Centre National de la Recherche Scientifique (CNRS), UMR 5310, Lyon, France.16 Medical and Infectious Diseases Intensive Care Unit, Hôpital Bichat-Claude-Bernard, and. 19 INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.No affiliation info available

Pub Type(s)

Journal Article
Multicenter Study
Observational Study

Language

eng

PubMed ID

27552490

Citation

de Montmollin, Etienne, et al. "Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care." American Journal of Respiratory and Critical Care Medicine, vol. 195, no. 4, 2017, pp. 491-499.
de Montmollin E, Demeret S, Brulé N, et al. Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care. Am J Respir Crit Care Med. 2017;195(4):491-499.
de Montmollin, E., Demeret, S., Brulé, N., Conrad, M., Dailler, F., Lerolle, N., Navellou, J. C., Schwebel, C., Alves, M., Cour, M., Engrand, N., Tonnelier, J. M., Maury, E., Ruckly, S., Picard, G., Rogemond, V., Magalhaes, É., Sharshar, T., Timsit, J. F., ... Sonneville, R. (2017). Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care. American Journal of Respiratory and Critical Care Medicine, 195(4), 491-499. https://doi.org/10.1164/rccm.201603-0507OC
de Montmollin E, et al. Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care. Am J Respir Crit Care Med. 2017 02 15;195(4):491-499. PubMed PMID: 27552490.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care. AU - de Montmollin,Etienne, AU - Demeret,Sophie, AU - Brulé,Noëlle, AU - Conrad,Marie, AU - Dailler,Frédéric, AU - Lerolle,Nicolas, AU - Navellou,Jean-Christophe, AU - Schwebel,Carole, AU - Alves,Mikaël, AU - Cour,Martin, AU - Engrand,Nicolas, AU - Tonnelier,Jean-Marie, AU - Maury,Eric, AU - Ruckly,Stéphane, AU - Picard,Géraldine, AU - Rogemond,Véronique, AU - Magalhaes,Éric, AU - Sharshar,Tarek, AU - Timsit,Jean-François, AU - Honnorat,Jérôme, AU - Sonneville,Romain, AU - ,, PY - 2016/8/24/pubmed PY - 2017/8/8/medline PY - 2016/8/24/entrez KW - anti–N-methyl-d-aspartate receptor KW - critical care KW - encephalitis KW - immunotherapy KW - incidence SP - 491 EP - 499 JF - American journal of respiratory and critical care medicine JO - Am J Respir Crit Care Med VL - 195 IS - 4 N2 - RATIONALE: Encephalitis caused by anti-N-methyl-d-aspartate receptor (NMDAR) antibodies is the leading cause of immune-mediated encephalitis. There are limited data on intensive care unit (ICU) management of these patients. OBJECTIVES: To identify prognostic factors of good neurologic outcome in patients admitted to an ICU with anti-NMDAR encephalitis. METHODS: This was an observational multicenter study of all consecutive adult patients diagnosed with anti-NMDAR encephalitis at the French National Reference Centre, admitted to an ICU between 2008 and 2014. The primary outcome was a good neurologic outcome at 6 months after ICU admission, defined by a modified Rankin Scale score of 0-2. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were included from 52 ICUs. First-line immunotherapy consisted of steroids (n = 61/74; 82%), intravenous immunoglobulins (n = 71/74; 96%), and plasmapheresis (n = 17/74; 23%). Forty-five (61%) patients received second-line immunotherapy (cyclophosphamide, rituximab, or both). At 6 months, 57% of patients had a good neurologic outcome. Independent factors of good neurologic outcome were early (≤8 d after ICU admission) immunotherapy (odds ratio, 16.16; 95% confidence interval, 3.32-78.64; for combined first-line immunotherapy with steroids and intravenous immunoglobulins vs. late immunotherapy), and a low white blood cell count on the first cerebrospinal examination (odds ratio, 9.83 for <5 vs. >50 cells/mm3; 95% confidence interval, 1.07-90.65). Presence of nonneurologic organ failures at ICU admission and occurrence of status epilepticus during ICU stay were not associated with neurologic outcome. CONCLUSIONS: The prognosis of adult patients with anti-NMDAR encephalitis requiring intensive care is good, especially when immunotherapy is initiated early, advocating for prompt diagnosis and early aggressive treatment. SN - 1535-4970 UR - https://www.unboundmedicine.com/medline/citation/27552490/Anti_N_Methyl_d_Aspartate_Receptor_Encephalitis_in_Adult_Patients_Requiring_Intensive_Care_ L2 - https://www.atsjournals.org/doi/10.1164/rccm.201603-0507OC?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -