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Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report.
J Neurosci Nurs. 2019 Aug; 51(4):194-197.JN

Abstract

N-methyl-D-aspartate receptor (NMDA-R) antibody encephalitis is an immune-mediated disorder characterized by the presence of anti-NMDA antibody in serum and cerebrospinal fluid, with a characteristic combination of psychological and neurological signs and symptoms. The scientific knowledge pertaining to the management of anti-NMDA-R encephalitis is growing. It is important that neuroscience nurses be aware of treatments as well as the newest novel treatment options available. Early aggressive intervention is imperative to recovery. The first line of treatment often includes high-dose steroids, intravenous immunoglobulin, and therapeutic plasma exchange. Second-line therapy for refractory NMDA-R encephalitis includes intravenous rituximab and cyclophosphamide. Even with these treatments, up to 25% of patients may be left with severe deficits or have a fatal outcome. It is well known that penetration of monoclonal anti-CD20 antibody therapy (rituximab) into the cerebrospinal fluid is 0.1% of that in the serum. Therefore, efficacy of rituximab in the treatment of NMDA encephalitis may be improved by intrathecal administration in selected cases with a poor response to intravenous rituximab. We present a case of anti-NMDA-R encephalitis that was refractory to first- and second-line therapies, who responded to intrathecal rituximab, to highlight a novel treatment that may be able to prevent long-term disability and improve clinical outcomes.

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Casares M
Questions or comments about this article may be directed to Maritsa Casares, BSN CNRN, at Maritsa.casares@flhosp.org. She is an Adult Clinical Coordinator, Florida Epilepsy Center, Florida Hospital, Orlando, FL. Holly J. Skinner, DO, is Epileptologist and Sleep Specialist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Elakkat D. Gireesh, MD, is Epileptologist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Christina Wombles, ARNP, is Nurse Practitioner, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Josephine Schweitzer, MSW, is Social Worker, Florida Epilepsy Center, Florida Hospital, Orlando, FL. P. Gage Gwyn, PhD ARNP, is Nurse Practitioner, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Herbert B. Newton, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Sherif M. Makar, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Kihyeong Lee, MD MSN, is Medical Director, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Michael Westerveld, PhD ABPP, is Director, Florida Hospital Medical Group, Florida Center for Neuropsychology, Orlando, FL.
Skinner HJ
No affiliation info available
Gireesh ED
No affiliation info available
Wombles C
No affiliation info available
Schweitzer J
No affiliation info available
Gwyn PG
No affiliation info available
Newton HB
No affiliation info available
Makar SM
No affiliation info available
Lee K
No affiliation info available
Westerveld M
No affiliation info available

MeSH

AdultAnti-N-Methyl-D-Aspartate Receptor EncephalitisAntineoplastic Agents, ImmunologicalCyclophosphamideElectroencephalographyFemaleHumansImmunosuppressive AgentsInjections, SpinalNeuroscience NursingRituximabSeizuresYoung Adult

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

31180943

Citation

Casares, Maritsa, et al. "Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: a Case Report." The Journal of Neuroscience Nursing : Journal of the American Association of Neuroscience Nurses, vol. 51, no. 4, 2019, pp. 194-197.
Casares M, Skinner HJ, Gireesh ED, et al. Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report. J Neurosci Nurs. 2019;51(4):194-197.
Casares, M., Skinner, H. J., Gireesh, E. D., Wombles, C., Schweitzer, J., Gwyn, P. G., Newton, H. B., Makar, S. M., Lee, K., & Westerveld, M. (2019). Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report. The Journal of Neuroscience Nursing : Journal of the American Association of Neuroscience Nurses, 51(4), 194-197. https://doi.org/10.1097/JNN.0000000000000450
Casares M, et al. Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: a Case Report. J Neurosci Nurs. 2019;51(4):194-197. PubMed PMID: 31180943.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report. AU - Casares,Maritsa, AU - Skinner,Holly J, AU - Gireesh,Elakkat D, AU - Wombles,Christina, AU - Schweitzer,Josephine, AU - Gwyn,P Gage, AU - Newton,Herbert B, AU - Makar,Sherif M, AU - Lee,Kihyeong, AU - Westerveld,Michael, PY - 2019/6/11/pubmed PY - 2020/3/28/medline PY - 2019/6/11/entrez SP - 194 EP - 197 JF - The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses JO - J Neurosci Nurs VL - 51 IS - 4 N2 - N-methyl-D-aspartate receptor (NMDA-R) antibody encephalitis is an immune-mediated disorder characterized by the presence of anti-NMDA antibody in serum and cerebrospinal fluid, with a characteristic combination of psychological and neurological signs and symptoms. The scientific knowledge pertaining to the management of anti-NMDA-R encephalitis is growing. It is important that neuroscience nurses be aware of treatments as well as the newest novel treatment options available. Early aggressive intervention is imperative to recovery. The first line of treatment often includes high-dose steroids, intravenous immunoglobulin, and therapeutic plasma exchange. Second-line therapy for refractory NMDA-R encephalitis includes intravenous rituximab and cyclophosphamide. Even with these treatments, up to 25% of patients may be left with severe deficits or have a fatal outcome. It is well known that penetration of monoclonal anti-CD20 antibody therapy (rituximab) into the cerebrospinal fluid is 0.1% of that in the serum. Therefore, efficacy of rituximab in the treatment of NMDA encephalitis may be improved by intrathecal administration in selected cases with a poor response to intravenous rituximab. We present a case of anti-NMDA-R encephalitis that was refractory to first- and second-line therapies, who responded to intrathecal rituximab, to highlight a novel treatment that may be able to prevent long-term disability and improve clinical outcomes. SN - 1945-2810 UR - https://www.unboundmedicine.com/medline/citation/31180943/Successful_Intrathecal_Rituximab_Administration_in_Refractory_Nonteratoma_Anti_N_Methyl_D_Aspartate_Receptor_Encephalitis:_A_Case_Report_ L2 - https://doi.org/10.1097/JNN.0000000000000450 DB - PRIME DP - Unbound Medicine ER -