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Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis.
Crit Care Med. 2018 09; 46(9):1514-1521.CC

Abstract

OBJECTIVES

Anti-N-methyl-D-aspartate receptor encephalitis is considered an immune-mediated form of encephalitis with paraneoplastic and nonparaneoplastic forms. Delay in recognition is common and patients typically present to the ICU without a diagnosis or with complications following a delayed diagnosis. The aim of this review is to provide a focused overview for the ICU clinician regarding presentation, diagnosis, and critical care management.

DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION

PubMed database search with manual review of articles involving anti-N-methyl-D-aspartate receptor encephalitis.

DATA SYNTHESIS

Anti-N-methyl-D-aspartate receptor encephalitis is increasingly encountered in the ICU. The cascade of events initiating anti-N-methyl-D-aspartate receptor antibody formation may involve an infectious trigger particularly in the setting of teratoma. Following a prodrome, most patients develop psychiatric symptoms followed by movement disorder. Classical, psychiatric, and catatonic phenotypes may be distinguished based on the presence and severity of symptoms. Early immunotherapy and low initial cerebrospinal fluid inflammation are independent predictors of positive outcomes in ICU patients. Concomitant organ failure, status epilepticus, and the identification of a tumor did not influence outcome in critically ill patients. Supportive care in the ICU includes management of various manifestations of dyskinesia, status epilepticus, autonomic disorders, and the need for general sedation. Common treatment strategies and limitations are discussed including the emerging role of bortezomib.

CONCLUSIONS

Intensivists should be familiar with the presentation and management of anti-N-methyl-D-aspartate receptor encephalitis. Early diagnosis and immediate implementation of steroids, immunoglobulins, and/or plasmapheresis and immune therapy are associated with a good neurologic outcome although response may be delayed. The selection and timing of second-line immune therapy requires further study.

Authors+Show Affiliations

Department of Pharmacy, Medical University of South Carolina, Charleston, SC.Department of Pharmacy, University of Utah Health, Salt Lake City, UT.Department of Neurosurgery, Medical University of South Carolina, Charleston, SC.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

29927776

Citation

Neyens, Ron R., et al. "Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis." Critical Care Medicine, vol. 46, no. 9, 2018, pp. 1514-1521.
Neyens RR, Gaskill GE, Chalela JA. Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Crit Care Med. 2018;46(9):1514-1521.
Neyens, R. R., Gaskill, G. E., & Chalela, J. A. (2018). Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Critical Care Medicine, 46(9), 1514-1521. https://doi.org/10.1097/CCM.0000000000003268
Neyens RR, Gaskill GE, Chalela JA. Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Crit Care Med. 2018;46(9):1514-1521. PubMed PMID: 29927776.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Critical Care Management of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. AU - Neyens,Ron R, AU - Gaskill,George E, AU - Chalela,Julio A, PY - 2018/6/22/pubmed PY - 2019/9/27/medline PY - 2018/6/22/entrez SP - 1514 EP - 1521 JF - Critical care medicine JO - Crit Care Med VL - 46 IS - 9 N2 - OBJECTIVES: Anti-N-methyl-D-aspartate receptor encephalitis is considered an immune-mediated form of encephalitis with paraneoplastic and nonparaneoplastic forms. Delay in recognition is common and patients typically present to the ICU without a diagnosis or with complications following a delayed diagnosis. The aim of this review is to provide a focused overview for the ICU clinician regarding presentation, diagnosis, and critical care management. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: PubMed database search with manual review of articles involving anti-N-methyl-D-aspartate receptor encephalitis. DATA SYNTHESIS: Anti-N-methyl-D-aspartate receptor encephalitis is increasingly encountered in the ICU. The cascade of events initiating anti-N-methyl-D-aspartate receptor antibody formation may involve an infectious trigger particularly in the setting of teratoma. Following a prodrome, most patients develop psychiatric symptoms followed by movement disorder. Classical, psychiatric, and catatonic phenotypes may be distinguished based on the presence and severity of symptoms. Early immunotherapy and low initial cerebrospinal fluid inflammation are independent predictors of positive outcomes in ICU patients. Concomitant organ failure, status epilepticus, and the identification of a tumor did not influence outcome in critically ill patients. Supportive care in the ICU includes management of various manifestations of dyskinesia, status epilepticus, autonomic disorders, and the need for general sedation. Common treatment strategies and limitations are discussed including the emerging role of bortezomib. CONCLUSIONS: Intensivists should be familiar with the presentation and management of anti-N-methyl-D-aspartate receptor encephalitis. Early diagnosis and immediate implementation of steroids, immunoglobulins, and/or plasmapheresis and immune therapy are associated with a good neurologic outcome although response may be delayed. The selection and timing of second-line immune therapy requires further study. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/29927776/Critical_Care_Management_of_Anti_N_Methyl_D_Aspartate_Receptor_Encephalitis_ L2 - https://dx.doi.org/10.1097/CCM.0000000000003268 DB - PRIME DP - Unbound Medicine ER -