Intrathecal methotrexate – Another tool for the treatment of refractory autoimmune encephalitis - Single institution cohort and literature review

Eaton, James E.; Kleinholz-Owens, Patricia; Subramaniam, Sriram; Pawate, Siddharama

doi:10.1016/j.jns.2021.120042

Cited by 5 publications

(3 citation statements)

References 19 publications

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“…En los casos en que exista recaída o alto riesgo de recurrencia, se puede usar micofenolato mofetilo (MMF) o azatioprina 13 . También se ha investigado la utilización de metotrexato intratecal, con resultados favorables, pero muy poca experiencia 14 .…”

Section: Discussionunclassified

Encefalitis autoinmune seronegativa asociada a síndrome de Sjögren primario

González Gómez,

De la Torre,

Pisoni

2023

Rev. Argent. Reumatol.

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La encefalitis autoinmune es un trastorno inmunomediado que compromete distintos territorios del parénquima cerebral, involucrando frecuentemente la materia gris profunda o la corteza, con o sin compromiso de la materia blanca, meninges o médula espinal. Se asocia frecuentemente con enfermedades autoinmunes o paraneoplásicas, y constituye un reto diagnóstico. Reportamos el caso de una mujer de 55 años con antecedentes de síndrome de Sjögren que consultó a Emergencias por cefalea y confusión. El líquido cefalorraquídeo (LCR) presentaba leucocitosis con neutrofilia. En la resonancia magnética nuclear (RMN) cerebral se evidenciaron múltiples imágenes de comportamiento restrictivo, de señal hiperintensa en T2 y FLAIR, a predominio córtico-subcortical a nivel occipital bilateral, hemisferio cerebeloso derecho y parietal derecho. Se descartaron infecciones y neoplasias. El panel de anticuerpos para encefalitis autoinmune aquaporina-4 y anti-MOG en LCR fue negativo. Recibió metilprednisolona endovenosa con mejoría progresiva de los síntomas.

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Section: Discussionunclassified

Encefalitis autoinmune seronegativa asociada a síndrome de Sjögren primario

González Gómez,

De la Torre,

Pisoni

2023

Rev. Argent. Reumatol.

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“…However, some cases showed a dramatic response temporally related to third-line treatments [40,43,60].…”

Section: Discussionmentioning

confidence: 99%

“…The efficacy of intrathecal methotrexate has been reported in individual series and in a pilot study including mainly patients with refractory anti-NMDAR encephalitis [60][61][62][63][64]. Most of the reported patients had a significant improvement that occurred early after the infusion (usually between 2 and 13 days) [60], even though some patients experienced a delayed improvement [61,63]. Cerebrospinal fluid antibody titers decreased after treatment, being the persistence of high titers associated with a lack of improvement [62].…”

Section: Intrathecal Methotrexatementioning

confidence: 99%

Treatment Options in Refractory Autoimmune Encephalitis

2022

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Autoimmune encephalitis represents a potentially treatable immune-mediated condition that is being more frequently recognized. Prompt immunotherapy is a key factor for the management of autoimmune encephalitis. First-line treatments include intravenous steroids, plasma exchange, and intravenous immunoglobulins, which can be combined in most severe cases. Rituximab and cyclophosphamide are administered as second-line agents in unresponsive cases. A minority of patients may still remain refractory, thus representing a major clinical challenge. In these cases, treatment strategies are controversial, and no guidelines exist. Treatments proposed for refractory autoimmune encephalitis include (1) cytokine-based drugs (such as tocilizumab, interleukin-2/basiliximab, anakinra, and tofacitinib); (2) plasma cell-depleting agents (such as bortezomib and daratumumab); and (3) treatments targeting intrathecal immune cells or their trafficking through the blood-brain barrier (such as intrathecal methotrexate and natalizumab). The efficacy evidence of these drugs is mostly based on case reports or small case series, with few reported controlled studies or systematic reviews. The aim of the present review is to summarize the current evidence and related methodological issues in the use of these drugs for the treatment of refractory autoimmune encephalitis.

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