32/M, h/o HSV encep 1 mo ago (s/p 21 d ACV), on ceftri/metronidazole for sacral OM, p/t ER +delusion, fever, seizure. CSF: WBC 25 (L>N), ⬆️TP, n/l gluc,(-)HSV. Septic w/u all(-). MRI:
b/l temporal lobe enhancement ⬆️ from prior. Whch of the ff is the best Tx for this condition?
1/11
The group is split b/n steroids & d/c metronidazole. The answer here is Tx w/ steroids. Indeed, this is a case of autoimmune post-HSV encephalitis (anti-NMDA receptor encephalitis post-HSV). Good job @LemuelNonMD
@LeMiguelChavez @adilrashid83 @Orchid10Tree @KhalafSuha
2/11
Metronidazole-induced encephalopathy is predominated by cerebellar Sx w/ a distinct involvement of the dentato-rubro-olivary pathway on imaging. We’ve talked about it here before. Refer👇for further discussion
3/11
Autoimmune post-HSV enceph is uncommon (7-12% adults, 14-27% children), 40+ cases bit.ly/3kLbK7g. Occurs 12-51 days after HSV enceph recovery, heralded by relapse of Sx (headache > fever/seizure) or worsening of residual neuro deficits👇 bit.ly/3i5B5as
4/11
Dominated by psych Sx (agitation, delusion, suicidality) in adults, movement d/o in children. MRI: worsened contrast enhancement, repeat LP: ⬇️ pleocytosis/protein elevation compared to prior HSV encep. Repeat CSF HSV PCR, neg in all cases. bit.ly/3i5B5as
5/11
Demonstration of Abs to the GluN1 subunit of the NMDA receptor (NMDAR) in the CSF is specific & diagnostic. Antibodies to other synaptic proteins (GABAR) have also been reported. Post-infectious anti-NMDAR encephalitis, thus far, has only been reported after HSV enceph.
6/11
Steroids, IVIG, or plasma exchange are the mainstay of Tx & often leads to remarkable improvement/normalization of Sx! Rarely, refractory cases have responded to rituximab.
7/11
Although uncommon, need to raise awareness in patients w/ relapse/worsening of Sx post-HSV encephalitis. In one study, the median for CSF Ab testing & immunotherapy from relapse of Sx was 85 & 79 days, respectively bit.ly/3i5B5as.
8/11
Anti-NMDAR enceph is the most characterized autoimmune enceph. Seen not only in post-HSV enceph, but as a distinct cause of enceph. It is a common cause of enceph, identified 4x as frequent as HSV, WNV, or VZV in the California Encephalitis Project bit.ly/2ECTnC5.
9/11
Anti-NMDAR non-post-HSV encephalitis has a predominant female predilection, >50% of whom have concurrent ovarian teratoma (buzzword for the boards). Other tumors identified: germ cell, small cell CA, Hodgkin. It is considered as a cause of paraneoplastic syndrome.
10/11
#idmesh The Exorcist & anti-NMDAR enceph!
1949, 14 yo boy admitted in Alexian Brothers Hospital St. Louis, MO w/ bizarre behavior, recovered after an exorcism procedure. Chronicled in the book👇, this has inspired the movie The Exorcist. @DxRxEdu @rabihmgeha @tony_breu
11/11
#idmesh This article lays out the striking similarity between this boy’s symptoms & anti-NMDAR encephalitis bit.ly/342jA5Q. Hope you learn something new. Please leave comments here. @ID_fellows @NNolanMD @swinndong @TxID_Edu @MedTweetorials @MohitHarshMD
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