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Rate of Autoimmune Encephalitis Among Children With First-Episode Psychosis
TAKE-HOME MESSAGE
- First-episode psychosis (FEP) can represent a diagnostic dilemma in children, and it is important to rule out the possibility of an autoimmune neuronal disease or metabolic disorder. In this study involving a retrospective cohort, the investigators aimed to determine the sensitivity of a previously developed FEP algorithm that recommends CSF testing if there are coexisting neurological symptoms; abnormal EEG, MRI, or serum neuronal antibody testing results; comorbidities; adverse effects; or resistance to antipsychotics. Interestingly, 100% of patients diagnosed with autoimmune encephalitis were recommended to undergo CSF testing, whereas only 32% of those who did not have autoimmune encephalitis were recommended to undergo CSF testing by the algorithm. The findings of this study translate into a 100% sensitivity and a 45.5% specificity, with a negative predictive value of 100%.
- This study confirms that a children's FEP algorithm is highly sensitive for identifying patients with autoimmune encephalitis.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND
Autoimmune encephalitis (AE) can present as first-episode psychosis (FEP) in children. An FEP diagnostic algorithm has been proposed, but how this algorithm applies to children is unknown. We assess the FEP diagnostic algorithm in children with FEP.
METHODS
The FEP algorithm was applied to a retrospective cohort of children with FEP without other neurological symptoms.
RESULTS
Twenty-four patients were included, with five AE (anti-N-methyl-d-aspartate receptor encephalitis) and 19 non-AE patients (12 primary psychiatric, two headaches, mycoplasma-related encephalitis, post-coronavirus disease 2019 encephalitis, drug reaction with eosinophilia and systemic symptoms [DRESS] syndrome, cobalamin C deficiency, and two unknown). Some non-AE patients (five of 19 = 26%) received immunotherapies, with symptom resolution in one of five (20%) with immunotherapy and in four of 14 (29%) without immunotherapy. The FEP algorithm recommended cerebrospinal fluid (CSF) testing in all (five of five = 100%) patients with AE and in six of 19 (32%) non-AE patients, resulting in 100% sensitivity (95% confidence interval [CI]: 100% to 100%) and 45.5% specificity (95% CI: 16% to 75%), with a negative predictive value of 100% (95% CI: 100% to 100%).
CONCLUSIONS
FEP can occur in children from different causes, including AE and metabolic conditions. Evaluation of FEP should be broad, especially without CSF evidence of inflammation. The FEP algorithm is useful to assess patients who would benefit from CSF testing and should be assessed in larger cohorts.
Additional Info
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Rate of Autoimmune Encephalitis in Children With First-Episode Psychosis
Pediatr. Neurol. 2024 Sep 16;161(xx)113-116, G Treiman, L Blackwell, R Howarth, G GombolayFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
First-episode psychosis in children is rare but has significant lifelong implications for the individual, the family, and the broader community. Autoimmune encephalitis, particularly anti–NMDA receptor encephalitis, is an important differential to consider early, given the improved outcomes with expeditious immunotherapy commencement, the need to exclude associated neoplasm, and the risk of neuroleptic sensitivity. Anti–NMDA receptor antibodies are present in up to 2% of individuals with first-episode psychosis,1 with a higher rate suspected among children; however, studies are limited, and no study has used CSF antibody confirmation.2 The lumbar puncture is not always available, especially in psychiatric settings, and can be difficult to achieve in distressed children or those with behavioral disorders. Making decisions around the extent to which invasive investigations should be conducted has to be assisted by proposed guidelines,3 but these have not been examined in child cohorts.
Treiman et al retrospectively reviewed 24 children with first-episode psychosis and no concurrent neurological features. The diagnosis of 5 patients with anti–NMDA receptor encephalitis was strictly defined with CSF antibody confirmation. They demonstrated a 100% sensitivity in detecting autoimmune encephalitis with the proposed guidelines, which would have halved the need for the lumbar puncture.
Importantly, the authors highlight the role of these guidelines to inform the commencement of immunotherapy. Although early initiation in patients with autoimmune encephalitis is vital, it may be detrimental in patients with primary psychiatric disorders. Not only does it expose the child to potential adverse effects, it may also delay the commencement of psychiatric care and impair psychoeducation, further propelling confusion and stigmatization. Cases of pediatric seronegative autoimmune encephalitis with psychosis are exceedingly uncommon when carefully assessed,4 and Treiman et al provide a clear explanation of why response to immunotherapy should not be solely considered as confirmation of diagnosis.
References