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Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 56-59

Anti-N-methyl-D-Aspartate-Receptor encephalitis following herpes simplex virus encephalitis – Presenting as a pediatric patient with abnormal movements and psychiatric manifestation

Department of Pediatrics, Sriramachandra Children's and Dental Hospital, Guntur, Andhra Pradesh, India

Correspondence Address:
Dr. Sravani Kolla
Sriramachandra Children's and Dental Hospital, Guntur, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_127_22

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Herpes simplex virus (HSV) encephalitis remains one of the more severe forms of childhood encephalitis. The clinical course of HSV encephalitis is usually monophasic but occasionally complicated by a clinical relapse, causing biphasic illness. Sometimes relapse may be due to secondary immune mechanisms. Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an example of immune-mediated relapse following herpes encephalitis. This is still underrecognized, with probable grave consequences if not treated early. Our index case was an 8-year-old male child with severe generalized choreoathetosis and behavioral disturbances, presented 4 weeks after documented HSV encephalitis. Cerebrospinal fluid (CSF) was positive for anti-NMDA receptor antibodies. The diagnosis was confirmed and treated with intravenous (IV) immunoglobulins (2 g/kg) and IV pulse-dose methylprednisolone (30 mg/kg) for 5 days. Other supportive management included tablet revocon 25 mg (tetrabenazine) ¼ tablet BD, clonazepam 0.25 mg one tablet BD, and syrup sizodon (risperidone) 0.5 mg BD. The patient is on regular follow-up and is recovering well but slowly. Patients with relapsing symptoms following HSV encephalitis or prolonged atypical symptoms, with repeat CSF-negative polymerase chain reaction for HSV should routinely be tested for NMDA receptor immunoglobulin G antibodies in CSF and/or serum. It is important to be aware of this differential diagnosis because patients respond well to immunotherapy.

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