Seronegative Autoimmune Encephalitis: A Challenge for the Neurologist.

[What is new] Patients with suspected autoimmune encephalitis and negative antibody assays are a common dilemma in Neurological practice. Antibody Prevalence in Epilepsy and Encephalopathy Score [APE2] and Response to Immunotherapy in Epilepsy and Encephalopathy Scores [RITE2] enhance the value of early case detection and treatment to prevent neurological sequel.

[What is old] Immunological studies in autoimmune neurological diseases may be negative despite characteristic clinical findings thus delaying diagnosis and treatment.

Seronegative autoimmune encephalitis is a term coined for patients who present with the triad of cognitive disturbances, seizures, and behavioral abnormalities but continue to evade antibody detection in serum and cerebrospinal fluid. The occurrence of seronegative autoimmune encephalitis is 48% despite the availability of the latest panel of antibody assays. The dilemma arises when patients, who present with the typical clinical and imaging findings of autoimmune encephalitis persist with negative antibody results. This case illustrates the importance of suspecting and treating seronegative IgLON5 disease with typical clinical features and life-threatening complications.

A 75-year-old man presented with progressive impairment of memory, mood swings, irritability, and excessive daytime sleepiness of 6-week duration. As time progressed, he experienced unsteadiness of gait, tremors, swallowing difficulty, and noisy breathing. Sleep was interrupted by snoring and rhythmic tapping of feet. Clinical examination revealed an elderly gentleman who had a loud audible inspiratory stridor. There was a dysexecutive syndrome comprising difficulty in planning, decision-making, temporal sequencing, poor attention span, and impaired abstract thinking, Glasgow coma score (GCS) was E3M6V4. He had a mask-like expression, low-toned speech, bilateral upgaze palsy, palatal involvement, cogwheel rigidity, and postural instability. Routine blood and urine examination were normal. Serum ammonia, free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone levels were normal. CSF was clear, cells 20 [100% lymphocytes], protein 46.80 mg/dL [normal 20–40 mg/dL], sugar 58.00 mg/dL [blood sugar 110 mg/dL]. Serology for herpes virus, and autoimmune and paraneoplastic antibodies were negative. Anti-thyroperoxidase antibody was 4.94 μm/mL [<30.00 μm/mL], and anti-thyroglobulin was 5.88 μm/mL [<30.00 μm/mL].

Paired serum and CSF by indirect immunofluorescence method did not show the presence of anti-IgLON5 antibodies. Electroencephalogram (EEG) revealed periodic short interval generalized discharges [Figure 1a]. Computed tomography (CT) of the brain revealed age-related cerebral atrophy. [Figure 1b]. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) of the brain revealed diffuse hypermetabolism in bilateral basal ganglia, midbrain, pons, vermis, and cerebellar hemispheres favoring autoimmune encephalitis [Figure 1c]. Sleep studies revealed a severe degree of obstructive apnea with apnea-hypopnea index (AHI) 63.6 and periodic limb movements in sleep [Figure 1d] for which CPAP titration studies were done. The patient had an Antibody Prevalence in Epilepsy and Encephalopathy [APE2] score of and Response to Immunotherapy in Treatment of Epilepsy and Encephalopathy [RITE2] score of 4 and 5 each [Tables 1a and b] before starting therapy. Based on the history, clinical presentation, EEG, imaging, polysomnography, negative serology, APE2, and RITE2 scores, a diagnosis of anti-IgLON5 disease was made, and the patient received plasma exchange followed by intravenous immunoglobulin and noninvasive ventilatory support. As he presented in an advanced stage of his illness, he succumbed and expired a fortnight later.

Figure 1

(a) EEG, (b) CT scan of brain, (c) FDG CT scan of the brain, (d) polysomnography.

Table 1a

Antibody Prevalence in Epilepsy and Encephalopathy Score [APE2]

Clinical features	Score
New-onset, rapidly progressive mental status changes emotional lability	+1
Autonomic dysfunction [presenting as labile blood pressure, labile heart rate, persistent tachycardia, postural hypotension]	+1
Viral prodrome [runny nose, sore throat, low-grade fever] only to be scored in the absence of underlying malignancy	0
Facial dyskinesias or faciobrachial dystonic movements	0
Seizure refractory to at least 2 antiseizure medications	0
CSF findings consistent with inflammation [elevated	+2
CSF protein level >50 mg/dL and/or lymphocytic pleocytosis >5 cells/dL, if the total number of CSF RBCs is <1000 cells/dL].
Brain MRI showing signal changes consistent with limbic encephalitis [medial temporal T2/FLAIR signal changes]	0
Presence of underlying malignancy [excluding cutaneous squamous cell or basal cell carcinomas]	0
Total	4

Table 1b

Response to Immunotherapy in epilepsy and encephalopathy score [RITE2]

Clinical features	Score
New-onset, rapidly progressive mental status changes that developed over 1–6 weeks or new-onset seizure activity (within 1 year of evaluation).	+1
Neuropsychiatric changes; agitation, aggressiveness, emotional lability.	+1
Autonomic dysfunction [sustained atrial tachycardia or bradycardia, orthostatic hypotension [≥ 20 mm Hg fall in systolic pressure or ≥10 mm Hg fall in diastolic pressure within 3 min of quiet standing], hyperhidrosis, persistently labile blood pressure, ventricular tachycardia, cardiac asystole, or gastrointestinal dysmotility.	+1
Viral prodrome [rhinorrhea, sore throat, low-grade fever] to be scored in the absence of underlying systemic malignancy within 5 years of neurological symptom onset.	0
Faciobrachial dystonic seizures	0
Facial dyskinesias, to be scored in the absence of faciobrachial dystonic seizures.	0
Seizure refractory to at least two antiseizure medications.	0
CSF findings consistent with inflammation [elevated CSF protein >50 mg/dL and/or lymphocytic pleocytosis >5 cells/mcL, if the total number of CSF RBC is <1000 cells/mcL].	+2
Brain MRI suggesting encephalitis [T2/FLAIR hyperintensity restricted to one or both medial temporal lobes, or multifocal in grey matter, white matter, or both compatible with demyelination or inflammation].	0
Systemic cancer diagnosed within 5 years of neurological symptom onset. [excluding cutaneous squamous cell carcinoma, basal cell carcinoma, brain tumor, cancer with brain metastasis].	0
Immunotherapy initiated within 6 months of symptom onset.	0
Neural plasma membrane autoantibody detected [NMDAR, GABAAR, GABABR, AMPAR, DPPX, mGluR1, mGluR2, mGluR5, LGI1, IgLON5, CASPR2 or MOG].	0
Total	5

Anti-IgLON5 disease, a new entity described in 2014, comprises a constellation of symptoms in four neurological domains which include sleep disorders, bulbar dysfunction, supranuclear gaze palsies, and cognitive decline.[12] Antibodies against neuronal cell adhesion proteins cause an irreversible internalization of IgLON-5 surface antigens with deposition of hyperphosphorylated tau in the hippocampus and brainstem.[12] Often the classical clinical picture, cerebrospinal fluid pleocytosis, and MRI findings of bilateral medial temporal hyperintensities occur in the absence of IgLON5 antibodies.[3] Seronegative autoimmune encephalitis represents patients with a well-defined neurological syndrome, cerebrospinal fluid pleocytosis, typical imaging findings, and a negative serology after excluding alternative causes.[345]

Antibody negative immune-mediated encephalitis has triggered the attention of many authors, as they have been several reports of patients with chronic refractory epilepsy, encephalopathy, and cognitive dysfunction requiring immunotherapy despite antiepileptic medication if the disease progresses further.[67] Initiation of treatment in suspected auto-antibody negative encephalitis prevents neuronal damage and memory impairment.[67] Early therapy averts sequel like hippocampal sclerosis, verbal and visual memory decline, and brainstem dysfunction in clinically suspected patients.[67]

At present, twenty serological tests are used for the detection of neural-specific autoantibodies in patients with autoimmune encephalitis [Table 1c].[7] However, despite the availability of a battery of tests, 48% of cases remain seronegative, and a consensus is achieved by including clinical and imaging findings.[67] The Antibody Prevalence in Epilepsy and Encephalopathy score [APE2] is a clinical scoring system used in the Mayo Clinic to estimate the probability of an autoimmune etiology in antibody-negative patients with an accurate prediction of the outcome.[67] [Table 1a] An APE score of 4 or more indicates the necessity for antibody testing.[6] The Response to Immunotherapy in Epilepsy and Encephalopathy score [RITE2] was derived at the Mayo Clinic from the analysis of retrospective studies to identify patients of autoimmune etiology who respond to immunotherapy.[7] A score of less than 7 is associated with refractoriness to immunotherapy [Table 1b]. The combined use of both these scales enables clinicians to apply an efficient evidence-based approach for the diagnosis of autoimmune neurological diseases in neurology clinics and busy hospitals where rapid screening is necessary.[67] Cognitive improvement following early immunotherapy cannot be overemphasized thus enhancing the value of these parameters in patients with negative antibody assays.[67]

Table 1c

Serological tests for the detection of neural-specific autoantibodies in patients with autoimmune encephalitis

Surface antigen associated	Intracellular antigen associated
Neural autoantibody	Neural autoantibody
1. AMPAR	11. AK5
2. LG1	12. Amphiphysin
3. CASPAR2	13. GAD-65
4. VGKCC [P/Q or Ntype]	14. ITPR1
5. DPPX	15. ZIC4
6. GABAAR	16. ANNA-1 [Hu]
7. GABABR	17. ANNA-2 [Ri]
8. IgLON5	18. CRMP5
9. MGluR1 – mGluR5	19. PCA-1[Yo]
10. NMDAR	20. Amphiphysin

Elderly people have a challenging time with autoimmune encephalitis due to the occurrence of age-related comorbidities that affect memory and cognition.[8] Older people have a higher chance of being antibody negative on routine testing in clinically suspected cases and 58.3% of seronegative limbic encephalitis can develop malignancy on subsequent follow-up visits.[8] In children, rapid cognitive decline, impairment of memory, refractory seizures, and dyskinesias are suggestive of an autoimmune etiology despite negative antibody results.[89] These scales are invaluable to enhance the yield of diagnosis in patients suspected of autoimmune encephalopathy or epilepsy irrespective of their age.[67]

Our patient had classical clinical and PET-CT findings of anti-IgLON5–mediated encephalitis with a negative antibody report, an APE2 score, and RITE2 score of 4 and 5 each [Tables 1a and b]. Young children and the elderly are vulnerable members of our society whose susceptibility to antibody-mediated illnesses and neurocognitive outcomes depend on the speed of instituting immunotherapy and disease-modifying agents.[89] Use of such scores should be strongly recommended when the tempo of illness is subacute, CSF is cellular, and PET scan is suggestive.[710] However, a larger study in such patients [clinically suggestive of IgLON5 encephalitis but antibody negative] needs to be done to validate these scores and bring them into the standard recommendation.

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Conflicts of interest

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