Therapeutic plasma exchange for the treatment of anti‐NMDA receptor encephalitis

Abstract

Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis is thought to be one of the common paraneoplastic-associated encephalitides. Between February 2001 and February 2011, nine patients were diagnosed with this disorder at Columbia University Medical Center: eight females (mean age 23 years) and one male (3 years of age). Four female patients had ovarian teratomas, which were removed as part of their treatment. Therapeutic plasma exchange (TPE) was used as one of the treatment modalities in addition to immunosuppressive therapy, including corticosteroids, intravenous immunoglobulin (IVIG), and/or rituximab. A total of 56 TPE procedures were performed in these patients on alternate days (range, 5-14 procedures/patient). Approximately 1 plasma volume (PV) was processed for all patients; 5% albumin and 0.9% normal saline were used as replacement fluid. Complications occurred in 20% of TPE procedures; 9% were possibly due to underlying disease. The remaining 11% of complications were hypotensive episodes that rapidly responded to either a fluid bolus or a vasopressor treatment. One patient demonstrated immediate clinical improvement after three TPE treatments, and four patients had significant improvement at time of discharge from the hospital. Long-term follow-up showed that early initiation of TPE appears to be beneficial, and patients who received IVIG after TPE did better than those who received IVIG before TPE. However, the number of patients in this series is too small to provide statistically significant conclusions. Overall, TPE is a relatively safe treatment option in patients with anti-NMDA-R encephalitis. Further studies are needed to elucidate the benefit of TPE in this disease.

Marked improvement of anti-N-methyl-D-aspartate receptor encephalitis by large-dose methylprednisolone and plasmapheresis therapy combined with 18F-fluorodeoxyglucose positron emission tomography imaging: A case report

“…In the present case study, the patient achieved considerable improvements following plasmapheresis initiated in the fourth week, following no effect from steroid treatment. This was consistent with a study by Pham et al (13) in which nine cases of anti-NMDA-R encephalitis were reviewed and two acquired the best recovery by undergoing plasmapheresis treatment. Thus, the authors of the current study continue to postulate that early plasmapheresis treatment may lead to beneficial treatment results.…”

Neuropsychological Profile of Anti-NMDA Receptor Encephalitis

“…Usually, tumor resection leads to complete recovery of clinical with few long-term neurological sequels (Tanyi, 2012;Boeck, 2013;Pham, 2011;Titulaer, 2013). It so occurred in our patient, with complete recovery of initial deficits in about a month of evolution.…”

Management of Immune-Mediated Paraneoplastic Neurological Disorders

“…In approx. 75 % of cases, second-line therapy results in further significant improvement of the symptoms [39,42,44,46]. In several cases and case series successful administration of other immunosuppressants, including azathioprine, methotrexate and mycophenolate mofetil, has been reported [49].…”

“…50 % of patients [39,44]. Controlled studies comparing the above-mentioned first-line immunotherapies are not available; however, a small series (n = 9) found an advantage for early plasma exchange treatment [46]. Given the direct pathogenetic role of NMDAR-Abs, the use of apheresis therapy is very reasonable.…”