Evaluation and Management of AE: A Clinical Overview for the Practicing Child Psychiatrist

The importance of awareness of AE among child psychiatrists has been emphasized in a recent publication by Mooneyham, Gallentine and VanMater of the Duke University Children’s Hospital Autoimmune Brain Disease Program. They note that the nature of early symptoms may lead children to be evaluated first by a psychiatrist. These may include the acute or subacute onset of: problems with thinking, memory, paranoia, insomnia, sensory disturbances, personality and behavioral changes, agitation, hallucinations, developmental regression and other symptoms. These may be mistaken for purely psychiatric disease. Younger children often initially present with movement disorders and seizures.

Studies have repeatedly shown that prompt diagnosis and treatment with immunotherapies leads to better outcomes in AE, so it is imperative that the condition be recognized and treated early.

Other important points about AE reviewed in this comprehensive article include:

• The two main goals of treatment of AE are to “decrease inflammation” and “to manage the symptoms of the disease to minimize ongoing injury.”
• “Child psychiatrists may be called on to advocate for their patients within the larger system to obtain the multidisciplinary evaluations necessary for treating autoimmune encephalitis.” They may also be consulted to help with the management of symptoms during immunotherapy treatment.
• There is significant variability among different types of AE and even within the same type from patient to patient. Patient outcomes are also quite variable and time to recovery can be long, taking 18 months or more.
• Anti-NMDAR is the most common type in children. About 40% of all anti-NMDAR encephalitis cases occur in children, however other types are known as well.
• The number of known antibodies is continuously increasing. Many investigators in the field believe there are far more antibodies to be discovered.
• Seronegative cases have become more widely recognized in the past few years. The diagnosis no longer relies on the response to immunotherapy or identification of an antibody; a clinical diagnosis can be made. Furthermore, “. . . limiting treatment only to those who have a known antibody will exclude many patients with AE who would equally benefit from immunotherapy.”
• Symptoms may still be present in the post-treatment period as the patient recovers. Working closely with the child’s team, which may consist of neurologists, immunologists and/or rheumatologists is advised as surveillance for flares and relapses is important.

Many thanks to Gena Mooneyham for sharing the article with us. Thanks also to Bill Gallentine and Heather VanMater for sharing in this important publication.

The abstract only is currently available to the public here.

by lynnchapman

• Research