AIM We report four cases of acquired severe encephalopathy with massive hyperkinesia, marked neurological and cognitive regression, sleep disturbance, prolonged mutism, and a remarkably delayed recovery (time to full recovery between 5 and 18mo) with an overall good outcome, and its association with anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies.METHOD We reviewed the four cases retrospectively and we also reviewed the literature. RESULTS Anti-NMDA receptor antibodies (without ovarian teratoma detected so far) were found in the two children tested in this study.
INTERPRETATIONThe clinical features are similar to those first reported in 1992 by Sebire et al., 1 and rarely recognized since. Sleep disturbance was not emphasized as part of the disorder, but appears to be an important feature, whereas coma is less certain and difficult to evaluate in this setting. The combination of symptoms, evolution (mainly seizures at onset), severity, paucity of abnormal laboratory findings, very slow recovery, and difficult management justify its recognition as a specific entity. The neuropathological substrate may be anatomically close to that involved in encephalitis lethargica, in which the same target functions (sleep and movement) are affected but in reverse, with hypersomnolence and bradykinesia. This syndrome closely resembles anti-NMDA receptor encephalitis, which has been reported in adults and is often paraneoplastic.In 1992, Sebire et al.1 reported a series of six children presenting with a novel combination of intense dyskinesia and severe regression with prolonged cognitive impairment but who made an unexpected excellent recovery.1 Since then, similar cases have been described. The disorder is sometimes called Sebire syndrome and is considered inflammatory or infectious in aetiology.2-5 Hartley et al., 6 in a paper entitled 'Immune-mediated chorea encephalopathy syndrome in childhood', specifically commented on the marked similarity between their cases and those of Sebire et al. Sleep disturbances (hypersomnolence) and dyskinesia (parkinsonism) are hallmarks of encephalitis lethargica, a condition increasingly recognized in children and presumed to be of autoimmune aetiology. In some cases, phases of insomnia and hyperkinesia, as in Sebire syndrome, may occur, suggesting that the localization of the acquired brain dysfunction may be in closely related areas and that common pathogenetic mechanisms are involved. This clinical picture is similar to the recently recognized entity, anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis, 7 which may be the underlying cause of the disorder reported by Sebire et al.We describe four new cases of Sebire syndrome, in which sleeplessness was a highly significant clinical feature 'masked' by severe dyskinesia and agitation, persisting long after dyskinesia had resolved. Anti-NMDA receptor antibodies were found in the two individuals who were tested. Their serum was analysed at the Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK (P...