D-aspartate Receptor Encephalitis Research Articles

Anti-NMDAR1 antibody impairs dendritic branching in immature cultured neurons.

Anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune disorder characterized by IgG antibodies targeting NMDAR. The prevalence is remarkably higher in women and some develop the condition during pregnancy. While immunotherapies have shown good outcomes for pregnant mothers and their infants, the impact on early neurodevelopment remains elusive. This study investigates the effects of anti-NMDAR antibody on the development of primary cortical cultures. Anti-NMDAR antibody was administered to the cultures at day in vitro 5 for the following 5 days to assess dendritic branching and arbor complexity, and at day in vitro 14 for measuring the expression of brain-derived neurotrophic factor (BDNF) and synaptic proteins. Immature cultured neurons treated with anti-NMDAR antibody exhibited impaired dendritic branching and arbor complexity. Interestingly, BDNF expression was unaffected in mature neurons. Additionally, GluN1 expression, a mandatory NMDAR subunit, was significantly reduced, while no significant alterations were observed in PSD-95, gephyrin and synaptophysin expression. These findings shed light on the structural and synaptic impacts of anti-NMDAR antibody on immature neurons, providing evidence for their consequences in early neuronal development.

Nonparaneoplastic anti-NMDA receptor encephalitis in an adolescent girl: a case report.

A 17-year-old female presented to the hospital with an 11-day history of fever, altered behavior, abnormal body movements, and altered sensorium. Upon examination, she was found to be febrile, tachycardic, and tachypneic, with a Glasgow Coma Scale score of 8. The diagnosis of anti-NMDA receptor encephalitis is usually confirmed by the presence of anti-NMDA receptor antibodies in the cerebrospinal fluid. The first-line treatment options include steroids, intravenous immunoglobulin, and plasmapheresis, while second-line therapies such as rituximab and cyclophosphamide may be necessary for some patients. While most patients respond well to treatment, complications can arise, and as in this case, death can occur. New onset symptoms like alteration in behavior, abnormal body movement, altered sensorium, and psychiatric symptoms in a young female should raise suspicion of this disease. Immunotherapy is promising; however, anticipation and management of complication are essential in reducing mortality.

Anti-NMDAR antibodies, watch the company they keep

Anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis is the most common and best described of the autoimmune encephalitis syndromes associated with neuronal cell surface or synaptic autoantibodies. It is typically characterised by a progressive clinical course involving confusion, psychosis, seizures, dysautonomia and altered consciousness and has increasingly been a diagnostic consideration for clinicians given greater awareness of its serious nature and potential response to immunosuppressive therapy.

Anti-N-methyl D-aspartate Receptor Encephalitis in India: A Literature Review.

Anti N-methyl D-aspartate receptor encephalitis (NMDAR-E) though rare, is currently considered as the commonest antibody mediated encephalitis in the world. No review on perspectives of NMDAR-E from India is available. The aim of the study was to review all the cases of NMDAR-E reported from India until June 2021 in terms of clinical features, diagnosis, and treatment, and perform a comparison of adult and paediatric cases. A literature review of NMDAR-E case reports/case series published from India till June 2021 was done. Demography, clinical profile, triggers, electroencephalography (EEG), neuroimaging, treatment details and outcomes were analysed. Sixteen case series and 35 case reports with a total of 249 cases were analysed. 82% of cases were from paediatric age group. The female to male ratio was 3:1. Psychiatric deficits, movement disorders, seizures, and language abnormalities were the most common clinical features. MRI brain abnormalities were seen in 45% patients. Electroencephalographic abnormalities were seen in 85% of patients. Infective triggers (herpes simplex virus and various other agents) were reported in 11% of the cases. Pediatric patients as compared with adults had more encephalopathy, autonomic dysfunctions, and normal imaging whereas the latter had more cognitive dysfunctions and delta brush pattern in electroencephalography (p<0.005). Therefore, to conclude, this literature review suggests that overall, the clinical spectrum of Indian cases is like cases described from other parts of the world. However, most reported cases from India belonged to paediatric age group who had more encephalopathy, autonomic dysfunctions, and normal brain imaging compared to adults. A few novel infectious agents as triggers were described from India.

Allied Health Rehabilitation of A Child With Anti-N-Methyl D-Aspartate (NMDA) Receptor Encephalitis – A Case Report on Presentation and Management

Allied Health Rehabilitation of A Child With Anti-N-Methyl D-Aspartate (NMDA) Receptor Encephalitis – A Case Report on Presentation and Management

Anti-N-methyl D-aspartate receptor encephalitis presenting with the new-onset refractory status epilepticus

Anti-N-methyl D-aspartate receptor encephalitis presenting with the new-onset refractory status epilepticus

Clinical characteristics, treatments, outcome, and prognostic factors of severe autoimmune encephalitis in the intensive care unit: Standard treatment and the value of additional plasma cell-depleting escalation therapies for treatment-refractory patients.

To investigate severe autoimmune encephalitis (AE) in the intensive care unit (ICU) with regard to standard treatment in responsive patients and additional escalation therapies for treatment-refractory cases. This retrospective, single-center study analyzed medical records of ICU-dependent AE patients for clinical characteristics, treatments, prognostic factors, and neurological outcome as quantified by modified Rankin Scale (mRS) and Clinical Assessment Scale for Autoimmune Encephalitis (CASE). From 40 enrolled patients (median age=52 years; range=16-89 years) with AE mediated by neuronal surface antibodies (nsAb; 90%) and AE with onconeuronal antibodies (10%), 98% received first-line therapy. Of those, 62% obtained additional second-line therapy, and 33% received escalation therapy with bortezomib and/or daratumumab. Good neurological outcome, defined as mRS=0-2, was observed in 47% of AE with nsAb (CASE=5), 77% of anti-N-methyl D-aspartate receptor encephalitis patients (CASE=1), whereas AE patients with onconeuronal antibodies had the poorest outcome (mRS=6, 100%). Treatment-refractory AE patients with nsAb requiring escalation therapy achieved similarly good recovery (mRS=0-2, 39%, CASE=3) as patients improving without (mRS=0-2, 54%, CASE=4), although they presented a higher disease severity at disease maximum (mRS=5 100% versus 68%, CASE=24 versus 17; p= 0.0036), had longer ICU stays (97 versus 23 days; p= 0.0002), and a higher survival propability during follow-up (p= 0.0203). Prognostic factors for good recovery were younger age (p= 0.025) and lack of preexisting comorbidities (p= 0.011). Our findings suggest that treatment-refractory AE patients with nsAb in the ICU can reach similarly good outcomes after plasma cell-depleting escalation therapy as patients already responding to standard first- and/or second-line therapies.

Acute Anti-N-Methyl D-Aspartate Receptor Encephalitis Following Covid-19 Vaccination

Acute Anti-N-Methyl D-Aspartate Receptor Encephalitis Following Covid-19 Vaccination

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis

Over the last 15 years, a new category of antibody-mediated diseases of the central nervous system (CNS) has been characterized and is now defined as "autoimmune encephalitis" (AE). There are currently 17 known AE syndromes, and all are associated with antibodies against the neuronal cell surface or synaptic proteins. The clinical syndromes are complex and vary according to the type of associated antibody. The best-known of these diseases is anti-N-methyl D-aspartate receptor (NMDAR) encephalitis, which is a prominent neuropsychiatric disorder associated with severe memory and behavioral impairments. The associated antibodies react with the GluN1 subunit of the NMDAR at the N-terminal domain. The approach most frequently used for the discovery and characterization of AE antibodies includes the culture of dissociated, fetal, rodent hippocampal neurons. During the process of antibody characterization, live neurons in culture are exposed to patients' serum or CSF, and the detection of reactivity indicates that the serum or CSF samples of the patient contain antibodies against neuronal surface antigens. Hippocampal cultures can also be used to determine whether the antibodies in patients are potentially pathogenic by examining if they cause structural or functional alterations of the neurons. The level of success of these studies depends on the quality of the cultures and on the protocols used to obtain and detect the reactivity of patient samples. This article provides an optimized protocol for primary cell culture of fetal rat hippocampal neurons combined with immunostaining to determine the presence of antibodies in the serum or CSF of patients. An example of how to examine the potential pathogenic effects of NMDAR antibodies using cultured neurons and calcium imaging is also presented.

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis.

Over the last 15 years, a new category of antibody-mediated diseases of the central nervous system (CNS) has been characterized and is now defined as "autoimmune encephalitis" (AE). There are currently 17 known AE syndromes, and all are associated with antibodies against the neuronal cell surface or synaptic proteins. The clinical syndromes are complex and vary according to the type of associated antibody. The best-known of these diseases is anti-N-methyl D-aspartate receptor (NMDAR) encephalitis, which is a prominent neuropsychiatric disorder associated with severe memory and behavioral impairments. The associated antibodies react with the GluN1 subunit of the NMDAR at the N-terminal domain. The approach most frequently used for the discovery and characterization of AE antibodies includes the culture of dissociated, fetal, rodent hippocampal neurons. During the process of antibody characterization, live neurons in culture are exposed to patients' serum or CSF, and the detection of reactivity indicates that the serum or CSF samples of the patient contain antibodies against neuronal surface antigens. Hippocampal cultures can also be used to determine whether the antibodies in patients are potentially pathogenic by examining if they cause structural or functional alterations of the neurons. The level of success of these studies depends on the quality of the cultures and on the protocols used to obtain and detect the reactivity of patient samples. This article provides an optimized protocol for primary cell culture of fetal rat hippocampal neurons combined with immunostaining to determine the presence of antibodies in the serum or CSF of patients. An example of how to examine the potential pathogenic effects of NMDAR antibodies using cultured neurons and calcium imaging is also presented.

Acute psychiatric symptoms in a young woman with anti-N-methyl D-aspartate receptor encephalitis: A case of successful early diagnosis and therapeutic intervention.

This clinical image presents a report on the diagnosis and treatment of anti‐NMDAR encephalitis, a rare disease. This report emphasizes the importance of a differential diagnosis for acute psychiatric symptoms. Accurate and timely diagnosis is critical for the selection and implementation of treatment and for optimal patient outcomes.

Disease Characteristics, Treatment, and Prognosis of Chinese Patients with Autoimmune Encephalitis: A Retrospective Study

To investigate the clinical features and prognosis of autoimmune encephalitis (AE). Accessing data from the electronic medical records of patients receiving care at West China Hospital, Sichuan University, China between 2013 and 2019, we conducted a retrospective study of the disease characteristics, laboratory examinations, treatment, and prognosis of AE patients. Before they were discharged, modified Rankin Scale (mRS) was used to assess the prognosis of AE patients and their mRS scores were then used to categorize patients as having good prognosis (mRS scores of 0-2) or poor prognosis (mRS scores of 3-6). Multivariate logistic regression was used to analyze risk factors associated with poor prognosis. A total of 121 patients were included in the study. The male-to-female ratio was 1∶1.1. At the time of diagnosis, patients were mainly from the age group of young to middle-aged individuals. Among the 121 patients, 64.5% (78 patients) had anti-N-methyl D-aspartate receptor (NMDAR) encephalitis, accounting for the largest proportion. 33.1% (40 patients) first visited the Department of Psychiatry for medical assistance. 62.8% (76 patients ) showed prodromal symptoms. The common clinical manifestations of the AE patients at the time of admission included cognitive dysfunction (104 patients, 86.0%), thought disorder (90 patients, 74.4%), and altered behaviors (88 patients, 72.7%). The NMDAR antibody titers were higher in the cerebrospinal fluid (CSF) than those in the serum. Double-positive antibodies were detected in 6 patients. No abnormality was observed in the brain magnetic resonance imaging (MRI) of 42 patients (34.7%) . Electroencephalography abnormalities were observed in 71 patients (58.7%). 111 patients (91.7%) received first-line immunotherapy and 61 patients (50.4%) still had neuropsychiatric deficits when they were discharged. Multivariate logistic regression revealed that consciousness disorder (odds ratio [ OR] =4.230, 95% confidence interval [ CI] : 1.540-11.617; P=0.005), altered behavior ( OR=2.997, 95% CI: 1.068-8.406; P=0.037) and movement disorder ( OR=7.753, 95% CI: 1.446-41.578; P=0.017) were risk factors for poor clinical prognosis of AE patients. Patients with AE mainly manifest cognitive damage. Half of the patients left neuropsychiatric deficits. The relationship between CSF titers and serum titers is unparalleled. The options of immunotherapy show no difference in their influence on prognosis. Cognitive dysfunction, altered behavior and movement disorder are independent risk factors for a poor prognosis at discharge.

Approach to Ovarian Dermoid Cysts in Context of Anti-NMDA Receptor Encephalitis: A Case Series

<h3>Study Objective</h3> Anti-<i>N</i>-methyl D-aspartate receptor (NMDA-R) encephalitis is a rare paraneoplastic syndrome associated with ovarian teratomas that carries significant morbidity and mortality. Treatment is via a multidisciplinary approach that must include ovarian cyst excision. <h3>Design</h3> Case series. <h3>Setting</h3> Hospital. <h3>Patients or Participants</h3> 1: A nulliparous 22-year-old woman, who was undergoing treatment for NMDA encephalitis, was referred to the gynaecology department with new diagnosis of right 7 cm ovarian dermoid cyst discovered with ultrasound screening. She had a BMI of 77 and type II respiratory failure with normal tumor markers. She underwent laparoscopic right oophorectomy and currently has ongoing surveillance of her left ovary. She remains independent in the community. 2: A 25-year-old nulliparous woman was admitted for anti-NMDA-R encephalitis. A CT abdo-pelvis demonstrated bilateral bulky ovaries and a 5 cm right ovarian dermoid cyst. A laparoscopic right salpingo-oophorectomy was performed. Intra-operatively, the left ovary was bulky but nil overt macroscopic lesions identified. Unfortunately, her neurological condition worsened. A pelvic MRI demonstrated normal left ovarian tissue, and a PET scan and tumour markers were unremarkable. Due to concerns of a microscopic ovarian teratoma contributing to her neurological deterioration, a laparoscopic left salpingo-oophorectomy was performed 14 months later. She gradually improved thereafter but requires ongoing care for neuropsychiatric deficits. <h3>Interventions</h3> Surgery. <h3>Measurements and Main Results</h3> Anti-NMDAR encephalitis syndrome develops when teratoma neural tissue stimulates the production of anti-NMDA-R antibodies [1]. These antibodies cause limbic neurone dysfunction and loss by altering cell-surface NMDA receptors, resulting in neuropsychiatric and autonomic symptoms [1]. Early immunotherapy and tumour resection improve the prognosis [1]. When deciding between cystectomy and oophorectomy, the gynaecologist must consider the ipsilateral recurrence rate after ovarian cystectomy (approximately 3-4 percent), the risk of incomplete removal of neural tissue, and intra-operative spillage [2]. <h3>Conclusion</h3> Ovarian teratoma associated with Anti-NMDA-R encephalitis requires urgent surgical intervention leading to favourable outcomes in this otherwise potentially devastating condition.

Catatonia in systemic lupus erythematosus: case based review.

Catatonia is a rare psychomotor syndrome characterized by stupor, posturing and echophenomena. It can be associated with schizophrenia, infections, drugs and autoimmune causes like anti N-methyl D-aspartate (NMDA) receptor encephalitis and systemic lupus erythematosus (SLE). Here we report two cases of systemic lupus erythematosus with catatonia, who improved with immunosuppressive treatment and review the cases described in the literature. The first case presented with fever, pancytopenia, toxic epidermal necrolysis (TEN)-like rash and later developed catatonia and macrophage activation syndrome (MAS). The second case presented with acute cutaneous lupus erythematosus (ACLE), fever, alopecia, polyarthralgias, nephritis, cytopenias along with catatonia. Successful management of this syndrome requires prompt recognition and treatment with immunosuppression as well as benzodiazepines with or without electroconvulsive therapy (ECT).

Status Epilepticus in Patients with Anti-NMDAR Encephalitis Requiring Intensive Care: A Follow-Up Study.

To date, specialized studies focusing on status epilepticus (SE) in anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis are limited, and the association between the occurrence of SE and clinical outcome is controversial. This study aims to investigate the differences between patients with critical anti-NMDAR encephalitis with SE and patients who experienced epileptic seizures without SE and to evaluate the long-term disease outcomes of patients with anti-NMDAR encephalitis with SE who were admitted to the neurological intensive care unit (neuro-ICU). In this retrospective study based on a prospective registry, patients with anti-NMDAR encephalitis with neuro-ICU admission from 2014 to 2019 were analyzed and divided into two groups based on whether they had SE. Their clinical characteristics during the neuro-ICU stay were assessed and compared. The neurological and seizure outcomes were evaluated every 3months. Of 83 patients with anti-NMDAR encephalitis, 24 required intensive care. In the SE group, 38.5% (5 of 13) of patients developed refractory SE (RSE), and 21.3% (3 of 13) of patients developed super RSE. More patients in the SE group presented with seizures as the initial symptoms (53.8% vs. 9.1%, p = 0.033) and had a strong positive NMDAR antibody titer in the cerebrospinal fluid (76.9% vs. 27.3%, p = 0.043). More patients in the non-SE group had a good neurological outcome (modified Rankin Scale (mRS) score < 2) at 3months after disease onset (60.0% vs. 15.4%, p = 0.039), but 83.3% of patients with SE had a mRS score < 2 at 9months after disease onset, which was similar to the rate in the non-SE group. A total of 41.7% of patients with SE had their last seizure within 1month from disease onset, which was significantly lower than the rate in the non-SE group (90%), but all the patients with SE became seizure free after the acute phase of disease. Patients with critical anti-NMDAR encephalitis who present with SE have a high rate of RSE/super RSE and recover more slowly than patients without SE, but most of them will eventually achieve good long-term neurological outcomes and live seizure free after the acute phase.

Autoimmune Encephalitis: Report of Two Pediatric Cases

Background: Autoimmune encephalitis (AIE) with neural cell autoantibodies is a treatable category of non-viral encephalitis in children and adolescents which presents with neuropsychiatric manifestations. Anti-N-methyl- D-aspartate receptor encephalitis, the most common identified type of AIE, is more frequent than individual viral encephalitis in young patients. Early diagnosis and treatment of the disease have been associated with improvement in the majority of patients.Case Report: we report two pediatric cases with acute neuropsychiatric presentations in whom the diagnosis of AIE was proved based on the cerebrospinal fluid (CSF) antineuronal antibodies in one and on clinical and paraclinical grounds in another seronegative patient. Immunotherapy in both patients resulted in improvement. No underlying tumor was found in patients.Pediatricians should be aware of manifestations, investigations, and treatment of AIE and consider it as the differential diagnosis of encephalitis.

Symptomatologic pathomechanism of N-methyl D-aspartate receptor encephalitis.

N-methyl D-aspartate receptor (NMDAR) encephalitis is a well-characterized clinical syndrome. The main molecular mechanism of NMDAR encephalitis is autoantibody-mediated NMDAR hypofunction in the neuronal synapse. Several pathomechanistic hypotheses might explain how NMDAR hypofunction causes the typical symptoms and prognosis of NMDAR encephalitis. Suppression of NMDAR-dependent gamma-aminobutyric acid interneurons provokes an accelerated activation of the positive feedback loops of the dorsolateral prefrontal cortex/subiculum-nucleus accumbens circuit in the striatum, the ventral tegmental area (VTA), and the nucleus reuniens in the thalamus-hippocampus-VTA loop. Dysregulated activation of the VTA and cortex via those positive feedback loops may explain the rapid clinical deterioration at acute stages of the disease and the well-characterized syndrome that includes limbic system dysfunction, intractable seizures, dyskinesia, coma, and the characteristic extreme delta brush. Progressive cerebellar atrophy is correlated with cumulative disease burden and is associated with worse long-term outcomes, which might be explained by the NMDAR-dependent pathways required to maintain neuronal survival. Those pathomechanistic hypotheses for NMDAR encephalitis support the rationale for the early introduction of combination immunotherapy and the use of adjuvant immunotherapy in patients with persisting symptoms in chronic disease phases.

Efficacy and safety of bortezomib in rituximab-resistant anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis as well as the clinical characteristics: An observational study

Treatment resistance leads to physiological, psychological, and economical effects among patients with anti-N-methyl d-aspartate receptor (anti-NMDAR) encephalitis, and the clinical and immune characteristics of these patients remain to be described. According to our clinical experience, bortezomib may be effective due to its plasma-cells depletion ability. Herein, the clinical presentations and immune parameters, including B cell and antibody secreting cell (ASC) abundance, of 5 enrolled treatment-resistant patients are described. When compared with 5 treatment-sensitive cases, the patients had serious clinical presentations but comparable B cells and ASCs. After receiving bortezomib, the ASC count and anti-NMDAR antibody titers decreased effectively. All 5 patients had a favorable prognosis (mRS ≤ 2) with a median follow-up of 31 months without severe side effects or relapse.

A case report of complement C4B deficiency in a patient with steroid and IVIG-refractory anti-NMDA receptor encephalitis

BackgroundComplement C4A or C4B deficiency has never been reported in autoantibody-associated encephalitides patient. Here we present a case of anti-N-methyl- D-aspartate (NMDA) receptor encephalitis associated with homozygous C4B deficiency, who did not respond to intravenous immunoglobulin and pulse methylprednisolone but plasmapheresis and rituximab.Case presentationA fourteen-year-old boy presented to our unit with subacute onset of behavioral changes and confusion, and was later confirmed to be anti-NMDA receptor encephalitis. He was initially managed with intravenous immunoglobulin (IVIG) and pulse methylprednisolone but did not achieve any clinical improvement. Seven sessions of plasmapheresis was commenced with remarkable improvement after the second session, and was followed by four doses of rituximab. His neurological and cognitive functioning gradually returned to baseline. Immunological investigations demonstrated persistently low C4 levels below 8 mg/dL. A more in-depth complement analysis of the patient and his family showed that he has homozygous C4B deficiency. Genetic analysis revealed that the index patient has homozygous deficiency in complement C4B and he carries one non-functioning mutant C4B gene inherited from his mother.ConclusionsLow levels of serum C4 correlate with reduced functions of the classical and lectin pathways, leading to the impairment of immune-complexes removal. Plasmapheresis ameliorates complement deficiency and removes the offending immune-complexes leading to clinical improvement that was not achieved by IVIG and steroids. We postulate that serum C4 levels may serve as a biomarker for the need of plasmapheresis upfront rather than only after non-response to steroid and IVIG in treating anti-NMDA-receptor encephalitis.

P62 Cyclophosphamide and maintenance mycophenolate mofetil for the treatment of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis in a paediatric patient

BackgroundAnti-NMDAR encephalitis is one of the commonest known types of autoimmune encephalitis with an increasing recognition in the paediatric population.1 2 It is characterised by abnormal behavioural and cognitive symptoms, seizures and movement disorders where treatment failure or failure to treat can result in long term disabilities or mortality.1A 4-year-old patient with a background of autism was admitted to the paediatric intensive care unit (PICU) due to encephalitis with convulsive status epilepticus where he remained intubated for 22 days and was later diagnosed with anti-NMDAR encephalitis. The patient had persistent abnormal choreoathetoid movements and intermittent seizures despite multiple anti-epileptics, two courses of corticosteroids, two courses of intravenous immunoglobulin, two cycles (10 sessions per cycle) of plasmapheresis and a course of weekly rituximab. Due to the lack of response from these initial pharmacological interventions, the use of cyclophosphamide and mycophenolate mofetil was considered. Cyclophosphamide and mycophenolate mofetil inhibits the proliferations of B- and T-lymphocytes3 4 which acts as the basis of its immunosuppressive actions. However, available evidence on the dosing and monitoring information in the paediatric population for this unlicensed indication is limited.Pharmacy ContributionsAfter discussion with the multi-disciplinary team (MDT) with extensive input from the paediatric neurologist, a literature search was conducted to determine an appropriate dosing regimen. As this was an off-label use, the paediatric neurologist and the attending consultant took clinical responsibility. Intravenous cyclophosphamide was started at 750 mg/m2 once a month for three cycles and oral mycophenolate mofetil was started at 600 mg/m2 twice a day as maintenance therapy a week after. The specialist pharmacist explained the individualised treatment plan for the patient to the MDT and ensured measures (hydration and mesna) for the prevention of cyclophosphamide-induced haemorrhagic cystitis were appropriately prescribed on the electronic prescribing system with the appropriate timings of administration. Monitoring parameters to determine adverse effects were closely observed. A local guideline was developed during the treatment cycles to ensure all members of the MDT were following the correct procedures.OutcomeThe patient responded to cyclophosphamide and clinically improved after the completion of three cycles of monthly treatment. Maintenance mycophenolate mofetil was subsequently stopped a month after the last cycle of cyclophosphamide due to neutropenia. A review of the patient one year after first presentation shows the patient is almost back to their baseline.Lessons LearnedAlthough there are potentially serious side effects, cyclophosphamide and mycophenolate mofetil has been successful in the treatment of anti-NMDAR encephalitis. The recovery of this patient required extensive support from the entire MDT.ReferencesNHS England. Clinical Commissioning Policy: Rituximab for second line treatment for anti-NMDAR autoimmune encephalitis (all ages). March 2018.Salvucci A, Devine IM, Hammond D, et al. Pediatric anti-NMDA (N-methyl D-Aspartate) receptor encephalitis. Pediatric Neurology 2014;50:507–510.Summary of Product Characteristics. Cyclophosphamide 1000 mg Powder for Solution for Injection or Infusion. Last updated on eMC on 27-Jun-2017. Available at https://www.medicines.org.uk/emc/product/3525/smpc# [Accessed 04 July 2019]Summary of Product Characteristics. CellCept 1 g/5 mL powder for oral suspension. Last updated on eMC on 16-Mar-2018. Available at https://www.medicines.org.uk/emc/product/1569/smpc [Accessed 04 July 2019]