[Update of clinical management in autoimmune encephalitis-2004].

Abstract

Encephalitis is a life-threatening disease with many causes. The continual discovery of newly identified forms of autoimmune encephalitis (AE) associated with antibodies to cell-surface or synaptic proteins has changed the paradigms for diagnosing and treating disorders. AE is one of the most common causes of non-infectious encephalitis. It can be triggered by tumors, infections, or it may be cryptogenic. These disorders can occur in patients with or without cancer. I review here the update of clinical management in AE. Recent clinical trends in AE include 1) the spread of clinical manifestations, 2) pitfalls of misdiagnosed cases and risk factors for misdiagnosis, and 3) treatment trends for refractory cases and symptomatic epilepsy. 1) The spread of clinical manifestations includes the presence of autoimmune psychosis (Pollak TA Lancet Psychiatry 2020), the presence of AE in adult-onset temporal lobe epilepsy (Kuehn JC, PLoS One 2020), and AE cases presenting with progressive dementia (Bastiaansen AEM, Neurol Neuroimmunol Neuroinflamm 2021). 2) Misdiagnosis and inappropriate use of diagnostic criteria for antibody-negative cases have been pointed out (Dalmau J. Lancet Neurol 2023). Misdiagnoses of AE occur for three reasons. First, non-adherence to reported clinical requirements for diagnostic criteria for AE. Second, the evaluation of inflammatory changes in head MRI and cerebrospinal fluid is insufficient. Third, absent or limited use of brain tissue assays along with use of cell-based assays that include only a narrow range of antigens. Red flags suggesting alternative diagnoses included an insidious onset, positive nonspecific serum antibody, and failure to fulfill AE diagnostic criteria. 3) Treatment trends for rituximab-resistant refractory cases include tocilizumab (IL6 receptor monoclonal antibody) and bortezomib (26S proteasome inhibitor). On the other hand, new Na channel inhibitors (lacosamide, etc.) and perampanel may be useful for treating symptomatic epilepsy in AE.