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Am J Respir Crit Care Med. 2017 Feb 15;195(4):491-499. doi: 10.1164/rccm.201603-0507OC.

Anti-N-Methyl-d-Aspartate Receptor Encephalitis in Adult Patients Requiring Intensive Care.

Author information

1
1 Polyvalent Intensive Care Unit, Centre Hospitalier de Saint-Denis, Saint-Denis, France.
2
2 Neurologic Intensive Care Unit, Hôpital Pitié-Salpêtrière.
3
3 Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, France.
4
4 Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nancy, Nancy, France.
5
5 Neurologic Intensive Care Unit, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, Hospices Civiles de Lyon, Lyon, France.
6
6 Department of Medical Intensive Care and Hyperbaric Medicine, Centre Hospitalier Universitaire d'Angers, Angers, France.
7
7 Medical Intensive Care Unit, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France.
8
8 Medical Intensive Care Unit, Hôpital Universitaire Albert Michallon, Grenoble, France.
9
9 Polyvalent Intensive Care Unit, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Poissy, France.
10
10 Medical Intensive Care Unit, Groupement Hospitalier Edouard Herriot, Hospices Civiles de Lyon, Lyon, France.
11
11 Neurologic Intensive Care Unit, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France.
12
12 Medical Intensive Care Unit, Hôpital de la Cavale Blanche, Centre Hospitalier Universitaire Régional de Brest, Brest, France.
13
13 Medical Intensive Care Unit, Hôpital Saint-Antoine.
14
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
15 French National Reference Centre for Paraneoplastic Neurologic Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; and.
16
16 Medical and Infectious Diseases Intensive Care Unit, Hôpital Bichat-Claude-Bernard, and.
17
17 Polyvalent Intensive Care Unit, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Paris, France.
18
18 Institut NeuroMyoGene, INSERM U1217/Centre National de la Recherche Scientifique (CNRS), UMR 5310, Lyon, France.
19
19 INSERM U1148, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.

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.

KEYWORDS:

anti–N-methyl-d-aspartate receptor; critical care; encephalitis; immunotherapy; incidence

PMID:
27552490
DOI:
10.1164/rccm.201603-0507OC
[Indexed for MEDLINE]

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