Kamei Satoshi
Center for Neuro-infections, Department of Neurology, Ageo Central General Hospital.
Rinsho Shinkeigaku. 2025 Jun 26;65(6):409-415. doi: 10.5692/clinicalneurol.cn-002102. Epub 2025 May 24.
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.
脑炎是一种由多种病因引起的威胁生命的疾病。与细胞表面或突触蛋白抗体相关的自身免疫性脑炎(AE)新确诊形式的不断发现,改变了疾病诊断和治疗的模式。AE是非感染性脑炎最常见的病因之一。它可由肿瘤、感染引发,也可能病因不明。这些病症可发生于有或无癌症的患者中。在此,我回顾AE临床管理的最新情况。AE近期的临床趋势包括:1)临床表现的扩展;2)误诊病例的陷阱及误诊风险因素;3)难治性病例和症状性癫痫的治疗趋势。1)临床表现的扩展包括自身免疫性精神病的出现(波拉克·T·A,《柳叶刀·精神病学》,2020年)、成人发作性颞叶癫痫中AE的存在(库恩·J·C,《公共科学图书馆·综合》,2020年),以及表现为进行性痴呆的AE病例(巴斯蒂亚森·A·E·M,《神经病学、神经免疫与神经炎症》,2021年)。2)抗体阴性病例的误诊及诊断标准的不当使用已被指出(达尔毛·J,《柳叶刀·神经病学》,2023年)。AE误诊有三个原因。第一,未遵循报道的AE诊断标准的临床要求。第二,对头部磁共振成像和脑脊液中炎症变化的评估不足。第三,脑组织检测缺乏或使用受限,同时仅使用包含有限范围抗原的基于细胞的检测方法。提示其他诊断的警示信号包括隐匿起病、非特异性血清抗体阳性以及未满足AE诊断标准。3)利妥昔单抗耐药难治性病例的治疗趋势包括托珠单抗(IL6受体单克隆抗体)和硼替佐米(26S蛋白酶体抑制剂)。另一方面,新型钠通道抑制剂(拉科酰胺等)和吡仑帕奈可能对治疗AE中的症状性癫痫有用。