Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients.
Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients.
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DOI：
10.3389/fpsyt.2017.00025
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发表时间：
2017
影响因子：
4.7
通讯作者：
Prüss H
中科院分区：
文献类型：
--
作者：
Herken J;Prüss H
引起各种精神症状的自身免疫机制越来越被认识到，并带来了神经精神病学的范式转变。对神经元离子通道或受体的潜在抗体的鉴定导致了许多患者被误诊为原发性精神疾病的猜测。然而，目前还没有明确的共识，精神病患者的哪些临床症状应该促使进一步的调查，包括抗神经元自身抗体的测量。因此，我们的目的是分析自身免疫性脑炎患者的表现症状以及症状发作和开始抗体诊断之间的时间。为此，我们于2016年5月至10月从自身免疫性脑炎慈善中心招募了100名患者，包括所有类型的自身免疫性脑炎。精神异常是最常见的临床症状，占60%。三分之一的患者最初住在精神科病房。所有n -甲基-d-天冬氨酸受体抗体阳性的患者均表现出行为改变、幻觉、记忆缺陷、紧张症或妄想。对其他细胞表面或细胞内抗原抗体阳性的患者常因心身诊断而住院。出现首次症状和抗体检测之间的时间往往延长得惊人。在2013年至2016年出现症状的患者中，平均延迟时间为74天，而在2007年至2012年诊断的病例中，平均延迟时间为483天，这表明尽管对这一新型疾病群体的认识提高有助于加快正确的诊断和治疗。通过详细分析医疗记录，我们确定了可能有助于早期诊断的临床症状，包括癫痫发作、紧张症、自主神经不稳定或运动亢进。事实上，使用这些“危险信号”重新分析整个队列导致症状发作和诊断之间的时间缩短了58%。我们的结论是，通过使用所描述的临床警告信号，可以促进自身免疫性精神疾病的及时诊断，可能实现早期免疫治疗和更好的预后。此外，脑脊液分析和自身抗体检测的阈值应该较低。
Autoimmune mechanisms causing diverse psychiatric symptoms are increasingly recognized and brought about a paradigm shift in neuropsychiatry. Identification of underlying antibodies against neuronal ion channels or receptors led to the speculation that a number of patients go misdiagnosed with a primary psychiatric disease. However, there is no clear consensus which clinical signs in psychiatric patients should prompt further investigations including measurement of anti-neuronal autoantibodies. We therefore aimed to analyze the presenting symptoms in patients with autoimmune encephalitis and the time between symptom onset and initiation of antibody diagnostics. For this, we recruited 100 patients from the Charité Center for Autoimmune Encephalitis between May and October 2016, including all types of autoimmune encephalitides. Psychiatric abnormalities were the most common clinical symptoms and were the presenting sign in 60%. One-third of patients were initially hospitalized in a psychiatric ward. All patients positive for antibodies against the N-methyl-d-aspartate receptor showed behavioral changes, hallucinations, memory deficits, catatonia, or delusions. Patients positive for antibodies against other cell surface or intracellular antigens were often hospitalized with a psychosomatic diagnosis. The time between occurrence of first symptoms and antibody testing was often alarmingly prolonged. In patients with symptom onset between 2013 and 2016, the mean delay was 74 days, in cases diagnosed between 2007 and 2012 even 483 days, suggesting though that increased awareness of this novel disease group helped to expedite proper diagnosis and treatment. By analyzing the medical records in detail, we identified clinical signs that may help to assist in earlier diagnosis, including seizures, catatonia, autonomic instability, or hyperkinesia. Indeed, reanalyzing the whole cohort using these “red flags” led to a 58% reduction of time between symptom onset and diagnosis. We conclude that the timely diagnosis of an autoimmune psychiatric disease can be facilitated by use of the described clinical warning signs, likely enabling earlier immunotherapy and better prognosis. Also, the threshold for cerebrospinal fluid analysis and autoantibody testing should be low.