复发性抗NMDA受体脑炎的临床特点及转归

Clinical features and prognosis of trecurrent anti-NMDA receptor encephalitis

摘要:

目的 探讨复发性抗N-甲基-D-天冬氨酸（NMDA）受体脑炎的临床特征、治疗、结局与转归。方法 选取2014年12月—2017年12月四川大学华西医院神经内科住院治疗的抗NMDA受体脑炎患者45例。其中复发性抗NMDA受体脑炎患者18例为观察组，随机选取非复发性抗NMDA受体脑炎患者27例为对照组，比较两组患者的临床特征、治疗与预后。结果 观察组首发表现为典型脑炎的9例（50%），对照组7例（26%），两组比较差异无统计学意义（P?>0.05）。观察组首发表现为癫痫持续状态的4例（22.2%），对照组4例（14.8%），两组比较差异无统计学意义（P?>0.05）。两组的脑脊液细胞增多、脑脊液蛋白水平升高、脑电图异常、头部MRI异常例数比较，差异均无统计学意义（P?>0.05）。比较脑脊液抗NMDA受体抗体与血清抗NMDA受体抗体检测预测复发的敏感性，差异有统计学意义（P?<0.05）。观察组转归良好的患者占72%，对照组转归良好的患者占85%，两组治疗结果及转归差异无统计学意义（P?>0.05）。结论 复发性和非复发性患者首发临床特点并无差异，出现癫痫持续状态与否与患者复发和预后并无确切联系。在评估是否复发时，脑脊液抗NMDA受体抗体较血清抗NMDA受体抗体更为敏感。抗NMDA受体脑炎复发与否对临床结局无显著影响。早期使用免疫治疗与联合二线免疫治疗可改善临床预后，但与抗NMDA受体脑炎复发率的降低无相关。

Abstract:

Objective To investigate the clinical features of recurrent anti-NMDA receptor (NMDAR) encephalitis. Methods Totally 18 recurrent anti-NMDAR encephalitis patients and 27 non-relapsing anti-NMDAR encephalitis who were admitted into West China Hospital during December 2014 to December 2017 were selected. Clinical features, treatment, clinical outcome and prognosis were recorded. Results In recurrent group, 9 (50%) cases presented as typical anti-NMDAR encephalitis and 4 cases (22.2%) presented as status epilepticus (SE). In non-recurrent group, 7 (26%) cases presented as typical anti-NMDAR encephalitis and 4 cases (14.8%) presented as status epilepticus (SE). No obvious difference in clinical manifestation was identified between 2 groups (P?>?0.05). No obvious difference in number of pleocytosis, protein concentration in cerebrospinal fluid, abnormal EEG and abnormal MRI were identified in two groups (P?>?0.05). Relapses rate was closely associated with tilter more often in CSF but not in serum (P?=?0.000). Rate of complete recovery accounted for 72% in relapsing patients, and that was 85% in non-relapsing patients. There was no significant difference between two group (P?> 0.05). Conclusions There is no difference in the initial clinical features between patients with recurrent and non-recurrent disease. There is no exact relationship between the status of epilepsy and the recurrence and prognosis. CSF anti-NMDA receptor antibodies are more sensitive than serum anti-NMDA receptor antibodies in assessing recurrence. The recurrence of anti-NMDA receptor encephalitis has no significant effect on clinical outcomes. Early use of immunotherapy and combined second-line immunotherapy can improve clinical outcomes, but is not associated with a reduction in the recurrence rate of anti-NMDA receptor encephalitis.