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Summary
Lancet Neurol 2018; 17: 760–72 Background Herpes simplex encephalitis can trigger autoimmune encephalitis that leads to neurological worsening.
Published Online We aimed to assess the frequency, symptoms, risk factors, and outcomes of this complication.
July 23, 2018
http://dx.doi.org/10.1016/
Methods We did a prospective observational study and retrospective analysis. In the prospective observational part of
S1474-4422(18)30244-8
this study, we included patients with herpes simplex encephalitis diagnosed by neurologists, paediatricians, or
See Comment page 733
infectious disease specialists in 19 secondary and tertiary Spanish centres (Cohort A). Outpatient follow-up was at 2,
*Study group members listed at
end of the Article
6, and 12 months from onset of herpes simplex encephalitis. We studied another group of patients retrospectively,
Neuroimmunology Program,
when they developed autoimmune encephalitis after herpes simplex encephalitis (Cohort B). We compared
Institut d’Investigacions demographics and clinical features of patients who developed autoimmune encephalitis with those who did not, and
Biomèdiques August Pi i in patients who developed autoimmune encephalitis we compared these features by age group (patients ≤4 years
Sunyer (IDIBAPS) compared with patients >4 years). We also used multivariable binary logistic regression models to assess risk factors
(T Armangue MD, M Spatola MD,
S Mattozzi, MD,
for autoimmune encephalitis after herpes simplex encephalitis.
M Cárceles-Cordon BS,
H Ariño MD, Findings Between Jan 1, 2014, and Oct 31, 2017, 54 patients with herpes simplex encephalitis were recruited to
E Martínez-Hernández MD, Cohort A, and 51 were included in the analysis (median age 50 years [IQR 5–68]). At onset of herpes simplex
A Saiz MD,
Prof M R Rosenfeld MD,
encephalitis, none of the 51 patients had antibodies to neuronal antigens; during follow-up, 14 (27%) patients
Prof F Graus MD, developed autoimmune encephalitis and all 14 (100%) had neuronal antibodies (nine [64%] had NMDA receptor
Prof J Dalmau MD), Laboratory [NMDAR] antibodies and five [36%] had other antibodies) at or before onset of symptoms. The other 37 patients
of Advanced Imaging in did not develop autoimmune encephalitis, although 11 (30%) developed antibodies (n=3 to NMDAR, n=8 to
Neuroimmunological Diseases
(IDIBAPS)
unknown antigens; p<0·001). Antibody detection within 3 weeks of herpes simplex encephalitis was a risk factor
(E Martinez-Heras PhD, for autoimmune encephalitis (odds ratio [OR] 11·5, 95% CI 2·7–48·8; p<0·001). Between Oct 7, 2011, and
S Llufriu MD), Service of Oct 31, 2017, there were 48 patients in Cohort B with new-onset or worsening neurological symptoms not caused
Neurology (S Llufriu, by herpes simplex virus reactivation (median age 8·8 years [IQR 1·1–44·2]; n=27 male); 44 (92%) patients had
C Montejo MD, A Saiz,
Prof F Graus, Prof J Dalmau),
antibody-confirmed autoimmune encephalitis (34 had NMDAR antibodies and ten had other antibodies). In both
Immunology Department, cohorts (n=58 patients with antibody-confirmed autoimmune encephalitis), patients older than 4 years frequently
Centre of Biomedical Diagnosis presented with psychosis (18 [58%] of 31; younger children not assessable). Compared with patients older than
(A Vlagea MD, M Juan MD), and
4 years, patients aged 4 years or younger (n=27) were more likely to have shorter intervals between onset of herpes
Microbiology Department
(M A Marcos MD), Hospital simplex encephalitis and onset of autoimmune encephalitis (median 26 days [IQR 24–32] vs 43 days [25–54];
Clínic, University of Barcelona, p=0·0073), choreoathetosis (27 [100%] of 27 vs 0 of 31; p<0·001), decreased level of consciousness (26 [96%] of
Barcelona, Spain; Pediatric 27 vs seven [23%] of 31; p<0·001), NMDAR antibodies (24 [89%] of 27 vs 19 [61%] of 31; p=0·033), and worse
Neuroimmunology Unit,
outcome at 1 year (median modified Rankin Scale 4 [IQR 4–4] vs 2 [2–3]; p<0·0010; seizures 12 [63%] of 19 vs
Neurology Department
(T Armangue, G Secondi MD), three [13%] of 23; p=0·001).
Department of Radiology
(J Muchart MD), and Functional Interpretation The results of our prospective study show that autoimmune encephalitis occurred in 27% of patients
Unit of Clinical Immunology
with herpes simplex encephalitis. It was associated with development of neuronal antibodies and usually presented
(A Vlagea, M Juan, L Alsina MD),
Research Institute of Sant Joan within 2 months after treatment of herpes simplex encephalitis; the symptoms were age-dependent, and the
de Déu Children’s Hospital, neurological outcome was worse in young children. Prompt diagnosis is important because patients, primarily those
University of Barcelona, older than 4 years, can respond to immunotherapy.
Barcelona, Spain; University of
Lausanne, Lausanne,
Switzerland (M Spatola); Funding Mutua Madrileña Foundation, Fondation de l’Université de Lausanne et Centre Hospitalier Universitaire
Section of Child Vaudois, Instituto Carlos III, CIBERER, National Institutes of Health, Generalitat de Catalunya, Fundació CELLEX.
Neuropsychiatry, Department
of Medical Surgical and
Copyright © 2018 Elsevier Ltd. All rights reserved.
Experimental Medicine,
Research in context University of Sassari (Sassari),
Italy (S Mattozzi); Department
Evidence before this study choreoathetosis, impaired level of consciousness, and refractory of Neurology, Complejo
Some patients with herpes simplex encephalitis develop seizures (often with infantile spasms) than were patients older Hospitalario de Navarra,
neurological relapses a few weeks after successful treatment of than 4 years. Older children and adults were more likely to Pamplona, Spain (M E Erro MD);
Department of Neurology,
the viral infection, but the frequency of this complication, present with cognitive changes and psychiatric symptoms. The Hospital Vall d’Hebron,
spectrum of symptoms, risk factors, and prognosis are largely symptoms in younger children (≤4 years) correspond to that Barcelona, Spain (L Abraira MD,
unknown. Autoimmune mechanisms were considered to be previously known as choreoathetosis after herpes simplex M Toledo MD); Department of
responsible, but the evidence was circumstantial and the target encephalitis, but the frequent presence of infantile spasms had Neurology, Hospital Central de
Asturias, Oviedo, Spain
antigens unknown. These targets were recently identified as the not been previously reported. The clinical features in older (G Moris MD); Department of
NMDA receptor (NMDAR) and other neurotransmitter children and adults were less known, and we show that Neurology, Hospital
receptors. We searched MEDLINE and Embase for articles psychosis is a frequent symptom presentation in this group Universitari i Politècnic La Fe,
published in English before April 1, 2018, using the MeSH terms (mainly if NMDAR antibodies are present). The main risk factor Valencia, Spain
(L Monros-Giménez MD,
“herpes simplex encephalitis”, “relapsing encephalitis”, for autoimmune encephalitis after herpes simplex encephalitis L Bataller MD); Hospital
“post-herpes simplex encephalitis”, “choreoathetosis”, “NMDA was the detection of autoantibodies (against NMDAR or Universitario Ramon y Cajal,
receptor antibodies”, or “N-methyl-d-aspartate receptor unknown cell-surface antigens) at follow-up 3 weeks after Madrid, Spain
(Í Corral-Corral MD);
antibodies”. We restricted searches to human studies. We also diagnosis of herpes simplex encephalitis. The neurological
Department of Neurology,
reviewed the reference lists of the papers identified by this outcome was worse in children aged 4 years or younger, as University of Pennsylvania, PA,
search. indicated by worse mean modified Rankin Scale scores and USA (Prof M R Rosenfeld,
greater number of seizures at 1 year. Prof J Dalmau); and Catalan
Added value of this study Institution for Research and
In this study, we describe the frequency, clinical features, risk Implications of all the available evidence Advanced Studies (ICREA),
factors, and prognosis of autoimmune encephalitis after herpes Findings from this study should raise awareness for Barcelona, Spain (Prof J Dalmau)
simplex encephalitis in two cohorts of patients. Cohort A is a autoimmune encephalitis after herpes simplex encephalitis. Correspondence to:
Prof Josep Dalmau,
prospective multicentre study of patients diagnosed with Detection of antibodies to NMDAR and other neurotransmitter
IDIBAPS-CELLEX, Casanova 143,
herpes simplex encephalitis. Cohort B is a retrospective study of receptors 3 weeks after the diagnosis of herpes simplex Barcelona 08036, Spain
patients who developed neurological worsening after herpes encephalitis is associated with the development of autoimmune jdalmau@clinic.cat
simplex encephalitis. The findings show that autoimmune encephalitis. Prompt recognition of this complication is
encephalitis after herpes simplex encephalitis is frequent, and important because patients, mainly older children and adults,
that the associated symptoms vary with patients’ age. Children respond better to immunotherapy.
aged 4 years or younger were more likely to develop
clinical features of patients who developed autoimmune Fever 49 (96%) 13 (93%) 36 (97%) p=0·490
encephalitis compared with those who did not develop Altered consciousness 35 (69%) 11 (79%) 24 (65%) p=0·335
autoimmune encephalitis or these features according to Abnormal behaviour 21 (41%) 5 (36%) 16 (43%) p=0·624
age group (patients ≤4 years compared with patients Memory deficits† 26/36 (72%) 6/8 (75%) 20/28 (71%) p=0·841
>4 years). Multivariate binary logistic regression models Aphasia† 28/36 (78%) 7/8 (88%) 21/28 (75%) p=0·431
were explored to identify predictor variables of developing Seizures 32 (63%) 11 (79%) 21 (57%) p=0·139
autoimmune encephalitis after herpes simplex Motor deficit 21 (41%) 8 (57%) 13 (35%) p=0·156
encephalitis. All variables with a cutoff p value of less CSF at diagnosis of herpes simplex encephalitis
than 0·1 (likelihood ratio test) in univariate binary Median white blood cell count per mm3 77 (22–170) 77 (22–122) 77 (22–190) p=0·545
logistic models and clinically meaningful variables Median protein concentration, mg/dL 60 (38–78) 62 (37–74) 57 (38–82) p=0·872
(patients’ age, % volume involvement on MRI, CSF Brain MRI abnormalities at diagnosis of herpes simplex encephalitis‡
pleocytosis, and protein concentration at 21 days) were FLAIR, mean % lesion volume 3·9% (3·3) 4·5% (3·9) 3·4% (2·9) p=0·344
considered for the multivariate binary logistic regression DWI, mean % lesion volume 3·7% (3·3) 3·6% (2·9) 3·8% (3·6) p=0·904
models, and approached by forward stepwise procedure Contrast enhancement 21/34 (62%) 6/8 (75%) 15/26 (58%) p=0·368
(appendix). We also explored first-order interactions Treatment of herpes simplex encephalitis
between variables. We used odds ratios (ORs) and Median time to start aciclovir, days§ 1 (0–2) 2 (1–2) 1 (0–3) p=0·193
95% CIs to measure the effect of predictors and adjusted Median duration of aciclovir treatment, 21 (16–21) 21 (18–23) 21 (15–21) p=0·548
for relevant variables if there was a clinically relevant days
change in the OR.21,22 In all analyses, we applied a bilateral Steroids¶ 20 (39%) 5 (36%) 15 (41%) p=0·752
type I error of 5% without a formal correction for ICU admission 27 (53%) 9 (64%) 18 (49%) p=0·315
multiplicity. We used STATA (version 13.1) for the Antiepileptic drugs 40 (78%) 12 (86%) 28 (76%) p=0·422
statistical analyses. Median modified Rankin Scale
At 6 months (n=48) 2 (1–3) 3 (3–4) 2 (1–3) p<0·001
Role of the funding source At 12 months (n=40) 2 (1–3) 3 (3–4) 2 (1–2) p<0·001
The funders of the study had no role in study design,
Data are median (IQR), n (%), n/N (%), or mean (SD). FLAIR=fluid-attenuated inversion recovery.
data collection, data analysis, data interpretation, or DWI=diffusion-weighted imaging. ICU=intensive care unit. *Likelihood ratio test. †Not assessable in 15 patients
writing of the report. The corresponding author had full (<3 years old, or severe decrease of the level of consciousness). ‡For lesion volume calculation, axial FLAIR sequences were
access to all the data in the study and had final available in 33 patients (19 without autoimmune encephalitis and 14 with autoimmune encephalitis), and axial DWI
sequences in 46 patients (32 without autoimmune encephalitis and 14 with autoimmune encephalitis). §The number
responsibility for the decision to submit for publication.
of days from onset of herpes simplex encephalitis symptoms to initiation of aciclovir. ¶17 patients were treated with
intravenous dexamethasone and three patients with intravenous methylprednisolone (with two also treated with
Results intravenous immunoglobulins).
Between Jan 1, 2014, and Oct 31, 2017, 54 patients with
Table 1: Demographics and clinical features of patients in Cohort A
herpes simplex encephalitis were recruited to Cohort A,
of whom 51 (n=50 HSV1 and n=1 HSV2) were included
in the analysis (n=3 died during the first 3 weeks of the In Cohort A, 37 (73%) of the 51 patients included in
disease; figure 1). The median time from neurological the analysis had progressive neurological improvement
symptom onset to inclusion in the study was 4 days or stable deficits; one patient died at week 9, from
(range 0–10); 29 (57%) patients were male. 48 (94%) aspiration pneumonia (an 11-year-old patient), one died
patients were followed-up for a minimum of 6 months; at week 10, from malignant thymoma (a 30-year-old
of the other three patients, one died at week 9, one died at patient), and one died at week 36, from lung
week 10, and one had less than 6 months of follow-up. complications (an 84-year-old patient; figure 1). 14 (27%)
40 (78%) were followed-up for 1 year; of the other eight patients developed new-onset CNS symptoms or
patients, one died at 9 months, one was lost to follow-up, worsening of previous deficits consistent with probable
and six had less than 1 year of follow-up. autoimmune encephalitis after herpes simplex
encephalitis (table 1). Median time from herpes patients who developed autoimmune encephalitis and
simplex encephalitis until probable autoimmune those who did not (table 1; appendix). Among patients
encephalitis was 32 days (IQR 22–43; range 7–61). who developed autoimmune encephalitis (n=14), MRI
Whereas all younger children (≤4 years; n=6; median scans at onset showed that nine (82%) of 11 patients had
age 9 months [IQR 3–12, range 2–15]) developed contrast enhancement comparable with that found
symptoms associated with choreoathetosis, all older during the viral encephalitis; similar findings were
children (>4 years) and adults (n=8, median age observed in patients who did not develop autoimmune
66 years [IQR 40–78, range 13–81]) developed symptoms encephalitis and had MRI at 1–3 months’ follow-up
without choreoathetosis in which behavioural and (six [60%] of ten patients, p=0·269; figure 2). Patients
psychiatric manifestations predominated (table 2). who developed auto immune encephalitis were more
Brain MRI scans at onset of herpes simplex likely to have necrosis with cystic lesions in MRI scans
encephalitis, with fluid-attenuated inversion recovery obtained at follow-ups later than 4 months after herpes
(FLAIR) and diffusion-weighted imaging (DWI), showed simplex encephalitis, compared with patients who did
no significant differences in lesion volume between not develop autoimmune encephalitis (nine [100%] of
mRS 3 weeks Day of onset and main Maximum Antibody findings at Day immunotherapy was mRS at Outcome at 12 months’
after herpes symptoms of mRS during diagnosis of autoimmune started 12 months follow-up after herpes
simplex autoimmune autoimmune encephalitis after herpes simplex encephalitis
encephalitis* encephalitis after herpes encephalitis simplex
simplex encephalitis encephalitis
Serum (titre) CSF (titre)
Patient #1 male, 2 Day 7: choreoathetosis 3 NMDAR NMDAR Not treated with 4 Developmental delay,
2 months old (1/200) (1/40) immunotherapy refractory epilepsy,
infantile spasms, cortical
blindness, microcephaly
Patient #2 male, 2 Day 24: choreoathetosis, 5 NMDAR NMDAR (titre Day 26: intravenous 3 Developmental delay,
3 months old refractory seizures, LCE, (1/1600) not available) methylprednisolone, plasma right-sided hemiparesis,
hypotonia, dysphagia exchange, rituximab microcephaly
Patient #3 female, 2 Day 25: choreoathetosis, 5 NMDAR NMDAR Day 25: intravenous 4 Developmental delay,
7 months old refractory seizures, status (1/800) (1/20) methylprednisolone, spastic tetraparesis,
epilepticus, infantile intravenous anarthria, and controlled
spasms, LCE, hypotonia, immunoglobulins; day 60: epilepsy
dysphagia rituximab, cyclophosphamide
Patient #4 male, 2 Day 19: refractory 5 NMDAR NMDAR Day 20: intravenous 5 Developmental delay,
11 months old seizures, infantile spasms, (1/200) (1/160) methylprednisolone, spastic tetraparesis,
LCE, hypotonia, intravenous refractory epilepsy
dysphagia, immunoglobulins, rituximab,
choreoathetosis cyclophosphamide; day 70:
plasma exchange
Patient #5 male, 2 Day 39: choreoathetosis, 5 NMDAR NMDAR Day 32: intravenous 3 Delay in language skills
12 months old loss of language skills, (1/800) (1/160) methylprednisolone,
LCE, hypotonia, dysphagia intravenous
immunoglobulins, rituximab
Patient #6 male, 2 Day 27: refractory status 5 NMDAR† NMDAR† Day 28: intravenous 4 Developmental delay,
15 months old epilepticus, hypotonia, (1/200) (1/80) methylprednisolone; day 44: refractory epilepsy
LCE, dysphagia, plasma exchange, rituximab
choreoathetosis
Patient #7 male, 4 Day 43: aggressive 5 NMDAR NMDAR Day 190: intravenous 3 Residual motor and
13 years old behaviour, psychosis, (1/800) (1/160) methylprednisolone cognitive deficits
headache, high blood
pressure
Patient #8 female, 2 Day 45: insomnia, anxiety, 3 NMDAR NMDAR Day 60: inatravenous 0 Complete recovery
34 years old irritability, fear, sleep (1/200) (1/80) methylprednisolone
fragmentation and
nightmares
Patient #9 male, 3 Day 44: headache, 4 Negative NMDAR Day 140: intravenous 3 Residual aphasia
45 years old confusion, agitation, (1/20) methylprednisolone
psychosis, insomnia,
delusional thoughts
Patient #10 4 Day 39: emotional lability, 4 Negative Unknown Day 160: intravenous 3 Anterograde amnesia
female, 56 years suicidal ideation, antigen (1/40) methylprednisolone
old psychosis, confusion
(Table 2 continues on next page)
mRS 3 weeks Day of onset and main Maximum Antibody findings at Day immunotherapy was mRS at Outcome at 12 months’
after herpes symptoms of mRS during diagnosis of autoimmune started 12 months follow-up after herpes
simplex autoimmune autoimmune encephalitis after herpes simplex encephalitis
encephalitis* encephalitis after herpes encephalitis simplex
simplex encephalitis encephalitis
Serum (titre) CSF (titre)
(Continued from previous page)
Patient #11 4 Day 37: confusion, 4 Negative Unknown Day 180: intravenous 4 Anterograde amnesia
female, 75 years aggressive behaviour, antigen (1/20) methylprednisolone,
old insomnia intravenous
immunoglobulins, rituximab,
cyclophosphamide
Patient #12 male, 3 Day 22: progressive 4 Unknown Unknown Day 159: intravenous 4 Anterograde amnesia
77 years old irritability, paranoid antigen antigen (1/20) methylprednisolone and irritability
thoughts, psychosis (1/800)
Patient #13 3 Day 17: fever, seizures, 5 Negative Unknown Day 21: steroids, intravenous 3 Anterograde amnesia
female, 78 years irritability, decreased level antigen (1/10) immunoglobulins, rituximab,
old of consciousness, cyclophosphamide
abnormal behaviour,
confusion, apathy
Patient #14 4 Day 63: progressive 4 Negative Unknown Day 90: intravenous steroids, 3 Anterograde amnesia
female, 80 years depression, apathy antigen intravenous
old (1/160) immunoglobulins
mRS=modified Rankin Scale. NMDAR=NMDA receptor. LCE=loss of contact with environment. *Except for patients 1, 4, and 13, who developed autoimmune encephalitis before the 3-week follow-up (figure
3A). †Coexisting GABAA receptor antibodies.
Table 2: Clinical features of patients with autoimmune encephalitis after herpes simplex encephalitis in Cohort A
nine patients vs seven [50%] of 14 patients; p=0·019; positive for IgG antibodies during follow-up (p<0·001),
figure 2). There were no differences in progression of including three (27%) with NMDAR antibodies and
local white-matter or grey-matter abnormalities or local eight (73%) with antibodies against unknown antigens
atrophy between patients who developed autoimmune (figure 3B). Compared with patients with autoimmune
encephalitis and those who did not (appendix). encephalitis, only five (14%) of 37 patients tested positive
CSF studies at onset of herpes simplex encephalitis for neuronal surface antibodies at the 3-week follow-up
and at 3 weeks’ follow-up showed no significant (p=0·0010). At 1-year follow-up, seven (50%) of 14 patients
differences in white blood cell count or total protein with autoimmune encephalitis and one (4%) of 26 patients
concentration between patients who subsequently dev without autoimmune encephalitis had antibodies
eloped autoimmune encephalitis and those who did not detectable in serum (p=0·0010; figure 3). The outcome of
(table 1; appendix). At the onset of autoimmune patients with autoimmune encephalitis who had
encephalitis, the PCR of CSF for HSV1 and HSV2 was persistent antibodies at 1-year follow-up was worse than
negative in all patients, and all patients had mild that of patients who became antibody negative (median
pleocytosis (median white blood cell count 17 per mm³ mRS 4 [IQR 3–5] vs 3 [3–3]; p=0·030).
[IQR 7–54]) and increased protein concentration (median The longest interval between herpes simplex
61 mg/dL [IQR 39–88]). encephalitis and autoimmune encephalitis was 61 days,
At onset of herpes simplex encephalitis, none of the and the sensitivity, specificity, positive predictive value,
51 patients included in the analysis of Cohort A had and negative predictive value for the detection of
antibodies against neuronal surface antigens. During neuronal surface antibodies within 2 months after
follow-up, all 14 (100%) patients who developed symptoms herpes simplex encephalitis are shown in the appendix.
consistent with autoimmune encephalitis tested positive In paired serum and CSF testing, neuronal surface
for IgG antibodies at or before the time of symptom antibodies were always present in CSF (19 [100%] of
onset, including nine (64%) patients with NMDAR 19 patients) and less frequently in serum (11 [58%] of
antibodies (n=1 with co-existing GABAA receptor 19 patients; figure 3). In six patients who did not develop
antibodies), and five (36%) with antibodies against autoimmune encephalitis, the antibodies were detected
unknown antigens (figures 3A, 4). Nine (64%) of these during the clinical follow-up when only serum was
14 patients were already antibody positive at the 3-week tested, according to the study design.
follow-up (six were antibody positive preceding onset of In the exploratory multivariate logistic regression
symptoms of autoimmune encephalitis); an example of analysis, the presence of autoantibodies at the 3-week
progressive NMDAR antibody development is shown in follow-up was identified as a risk factor for autoimmune
the appendix. By contrast, among the 37 patients who did encephalitis (OR 11·5, 95% CI 2·7–48·8; p<0·001;
not develop autoimmune encephalitis, 11 (30%) tested appendix). Adjustment by patient’s age and other possible
HSE 1–3 months 6–9 months HSE 1–3 months 6–9 months
Case 1
(patient 4)
Case 2
(patient 10)
Case 3
Case 4
(patient 24)
Figure 2: MRI in patients who developed autoimmune encephalitis after herpes simplex encephalitis compared with those who did not develop autoimmune
encephalitis
Each row corresponds to a different patient and includes MRI scans obtained at diagnosis of herpes simplex encephalitis, at 1–3 month follow-up, and at 6–9 month
follow-up. The first three columns of images correspond to FLAIR sequences, and the last three columns to T1 sequences, all with contrast (except for the 6–9 month
T1 follow-up for patient 4). Case 1 (patient 4) was an 11-month-old boy who developed autoimmune encephalitis with NMDAR antibodies after herpes simplex
encephalitis. Case 2 (patient #10) was a 56 year-old woman who developed autoimmune encephalitis with antibodies against unknown neuronal surface antigens
after herpes simplex encephalitis. Case 3 (no patient number) was a 49 year-old woman who developed herpes simplex encephalitis without autoimmune
encephalitis or neuronal antibodies (she had history of lung adenocarcinoma, brain metastasis, and cranial radiotherapy). Case 4 (patient #24) was a 66 year-old
woman who developed NMDAR and GAD65 antibodies but did not have symptoms of autoimmune encephalitis. These patients were chosen because there was
good MRI follow-up and they were representative of the indicated subgroups. In all patients, MRI scans obtained at the 1–3 month follow-up show areas of FLAIR
hyperintensity (larger or similar to those obtained at diagnosis of herpes simplex encephalitis); however, MRIs of patients who developed autoimmune encephalitis
(first and second rows) show more extensive areas of post-necrotic cystic abnormalities than those who did not develop autoimmune encephalitis (third and fourth
rows). Note that all patients, except patient 24, have areas of contrast enhancement at 1–3 month follow-up. FLAIR=fluid-attenuated inversion recovery. HSE=herpes
simplex encephalitis. NMDAR=NMDA receptor.
effect modifiers was not associated with a clinically developed new-onset or worsening neurological
meaningful change in OR (appendix). symptoms not caused by herpes simplex virus
At 1-year follow-up, patients who developed autoimmune reactivation after completing treatment with aciclovir
encephalitis had more neurological deficits (median (figure 1). Of these 48 patients, 44 (92%) had neuronal
mRS 3 [IQR 3–4] vs 2 [1–2]; p<0·001; table 1) and were surface antibodies; 34 (77%) of 44 had antibodies
more frequently treated with anti-epileptic drugs than against NMDAR and the other ten (23%) had antibodies
were those who did not develop autoimmune encephalitis against unknown antigens (appendix). Antibodies were
(ten [71%] of 14 patients vs nine [35%] of 26; p=0·046). more frequently detected in CSF (44 [100%] of
Between Oct 7, 2011, and Oct 31, 2017, 48 patients 44 patients; median titres 1/40 [IQR 1/10 to 1/160]) than
were included in Cohort B (median age 8·8 years in serum (25 [76%] of 33 patients, median titres 1/800
[IQR 1·1–44·2]; 26 male patients). These patients [1/400 to 1/3200]; appendix).
A
Patient Sex Age Sample HSE Day 21 Day 60 Day 180 Day 365 Antigen Serum titres
Highest* Day 365
1 Male 2 months CSF – + NMDAR 1/3200 1/800
Day 7
Serum – + + + +
mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 Day of onset of autoimmune encephalitis
The median time from herpes simplex encephalitis hypotonia, dysphagia, and frequent refractory seizures
until symptoms of probable autoimmune encephalitis in (table 3). Six (22%) of these 27 patients developed infantile
Cohort B was 31 days (IQR 25–49, range 11–306). Similar spasms during the acute phase of autoimmune en
to patients from Cohort A, patients who were aged 4 years cephalitis, and another two at later stages (6–12 months’
or younger (n=21, median age 10·6 months [IQR 7–20, follow-up). By contrast, patients older than 4 years (n=31)
range 4·5–48]) developed symptoms associated with developed prominent change of behaviour and psychiatric
choreoathetosis, whereas those older than 4 years (n=23, symptoms, had less frequent seizures or decreased level of
median age 34 years [16–56, range 6–69]) developed consciousness, and no choreoatherosis. 18 (58%) of these
symptoms in which behavioural and psychiatric 31 patients presented with psychosis (in younger children,
manifestations predominated (appendix). Of the total psychosis was not assessable). Compared with patients
48 patients in Cohort B, the remaining four (8%) patients older than 4 years, patients aged 4 years or younger (all
without neuronal surface antibodies had main clinical with choreoathetosis) were more likely to have a shorter
features of epileptic seizures (n=3) and behavioural interval between herpes simplex encephalitis and
change (n=1; appendix). autoimmune encephalitis, seizures, decreased level of
Considering all 58 patients from both cohorts who consciousness, NMDAR antibodies, and worse outcome at
developed antibody-associated autoimmune encephalitis 1 year, including a higher mRS score and more frequent
after herpes simplex encephalitis, we identified symptoms seizures than patients older than 4 years (table 3).
that were age-dependent: patients aged 4 years or younger Compared with patients with antibodies other than
(n=27) developed prominent choreoathetosis, behavioural NMDAR (n=15), patients with NMDAR antibodies (n=43)
change, decreased level of consciousness, truncal were more likely to be younger and develop psychosis,
B
Patient Sex Age Sample HSE Day 21 Day 60 Day 180 Day 365 Antigen Serum titres
Highest* Day 365
15 Female 12 CSF – + NA Unknown 1/12 800 NA
months Serum – + + +
mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 Day of onset of autoimmune encephalitis
Figure 3: Timing of antibody detection, development of autoimmune encephalitis, and follow-up of serum testing and neurological status
(A) Patients from Cohort A who developed neuronal surface antibodies in association with autoimmune encephalitis. None of the patients had neuronal surface antibodies at the time of onset of
herpes simplex encephalitis, but all were antibody-positive at or before onset of symptoms of autoimmune encephalitis. In all patients, the presence (+) or absence (–) of neuronal cell-surface
antibodies in serum was followed for 1 year. The neurological status was measured with the mRS and is colour-coded. (B) Patients from Cohort A who developed neuronal surface antibodies without
autoimmune encephalitis. These patients became antibody-negative sooner (as measured in serum) than did patients with autoimmune encephalitis. HSE=herpes simplex encephalitis.
NMDAR=NMDA receptor. NA=not available. mRS=modified Rankin Scale. *In all patients, the highest serum titres were identified within the first 2 months of follow-up. †NMDAR antibodies with
co-existing GABAA receptor antibodies. ‡NMDAR antibodies with co-existing GAD65 antibodies; at 1 year follow-up only GAD65 antibodies remained detectable (not shown).
choreoathetosis, decreased level of consciousness, and different outcomes in the retrospective Cohort B, in
dysautonomia (appendix). No differences in neurological which patients who developed unexplained neurological
outcome (mRS) were noted between patients with symptoms after treatment of herpes simplex encephalitis
autoimmune encephalitis with NMDAR antibodies and were investigated for antibodies against neuronal
those with other neuronal surface antibodies (appendix). surface proteins.
When Cohort A was examined for risk factors of
Discussion autoimmune encephalitis, the main feature identified
In the prospective Cohort A, 27% of patients with herpes was the detection of neuronal antibodies at 3-week
simplex encephalitis developed symptoms of auto follow-up. Considering that none of the patients tested
immune encephalitis within 3 months of completing positive for these antibodies at onset of herpes simplex
treat
ment with aciclovir; neurological symptoms, encephalitis, this finding suggests the viral infection
response to immunotherapy, and long-term outcome triggered the immune response. We do not know
varied according to the patients’ age. Patients aged 4 years whether any of these immune responses occurred as a
or younger developed choreoathetosis, decreased level result of viral-induced release of NMDAR and other
of consciousness, and frequent seizures or infantile proteins, or by mechanisms of molecular mimicry, such
spasms, whereas children aged more than 4 years and as similarity between NMDAR and herpes simplex virus
adults predominantly developed a change of behaviour proteins. The high frequency of antibodies against
and psychiatric symptoms sometimes accompanied by different neuronal antigens supports the first possibility
seizures. Additionally, older children and adults were but does not rule out that molecular mimicry might also
more likely to respond to immunotherapy. There were be involved. One study23 showed that patients with
similar findings regarding age-related symptoms and classic anti-NMDAR encephalitis (not herpes simplex
A B
C D
E F
500 µm 10 µm
encephalitis-related) were more likely to have herpes preceded the onset of autoimmune encephalitis, and
simplex virus anti bodies than were an age-matched that not all antibody-positive patients developed neuro
control population, suggesting the possibility of logical worsening. Moreover, at 1-year follow-up,
molecular mimicry between herpes simplex virus and seven (50%) of 14 patients who developed autoimmune
NMDAR.23 Although the role of human leukocyte encephalitis remained IgG antibody positive despite the
antigen in predisposing people to anti-NMDAR use of immunotherapy in 13 cases, whereas one (4%) of
encephalitis is still unclear,24,25 future studies should 26 patients who did not develop autoimmune
determine whether there is a predisposition among encephalitis and therefore did not receive immuno
patients with herpes simplex encephalitis to develop therapy remained antibody positive. These findings
autoimmune encephalitis. indicate that herpes simplex encephalitis can initiate, in
In Cohort A, clinical and immunological follow-up some patients, a transient and subclinical synthesis of
showed that the development of autoantibodies neuronal antibodies that becomes undetectable several
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