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Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti–N-Methyl-D-Aspartate Receptor Encephalitis

A Case Report

Casares, Maritsa; Skinner, Holly J.; Gireesh, Elakkat D.; Wombles, Christina; Schweitzer, Josephine; Gwyn, P. Gage; Newton, Herbert B.; Makar, Sherif M.; Lee, Kihyeong; Westerveld, Michael

Journal of Neuroscience Nursing: August 2019 - Volume 51 - Issue 4 - p 194–197
doi: 10.1097/JNN.0000000000000450
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ABSTRACT N-methyl-D-aspartate receptor (NMDA-R) antibody encephalitis is an immune-mediated disorder characterized by the presence of anti-NMDA antibody in serum and cerebrospinal fluid, with a characteristic combination of psychological and neurological signs and symptoms. The scientific knowledge pertaining to the management of anti–NMDA-R encephalitis is growing. It is important that neuroscience nurses be aware of treatments as well as the newest novel treatment options available. Early aggressive intervention is imperative to recovery. The first line of treatment often includes high-dose steroids, intravenous immunoglobulin, and therapeutic plasma exchange. Second-line therapy for refractory NMDA-R encephalitis includes intravenous rituximab and cyclophosphamide. Even with these treatments, up to 25% of patients may be left with severe deficits or have a fatal outcome.1 It is well known that penetration of monoclonal anti-CD20 antibody therapy (rituximab) into the cerebrospinal fluid is 0.1% of that in the serum.2 Therefore, efficacy of rituximab in the treatment of NMDA encephalitis may be improved by intrathecal administration in selected cases with a poor response to intravenous rituximab. We present a case of anti–NMDA-R encephalitis that was refractory to first- and second-line therapies, who responded to intrathecal rituximab, to highlight a novel treatment that may be able to prevent long-term disability and improve clinical outcomes.

Questions or comments about this article may be directed to Maritsa Casares, BSN CNRN, at Maritsa.casares@flhosp.org. She is an Adult Clinical Coordinator, Florida Epilepsy Center, Florida Hospital, Orlando, FL.

Holly J. Skinner, DO, is Epileptologist and Sleep Specialist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL.

Elakkat D. Gireesh, MD, is Epileptologist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL.

Christina Wombles, ARNP, is Nurse Practitioner, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL.

Josephine Schweitzer, MSW, is Social Worker, Florida Epilepsy Center, Florida Hospital, Orlando, FL.

P. Gage Gwyn, PhD ARNP, is Nurse Practitioner, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL.

Herbert B. Newton, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL.

Sherif M. Makar, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL.

Kihyeong Lee, MD MSN, is Medical Director, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL.

Michael Westerveld, PhD ABPP, is Director, Florida Hospital Medical Group, Florida Center for Neuropsychology, Orlando, FL.

E.D.G. has served as a consultant/researcher for UCB. P.G.G. is a part of the speakers’ bureau for INCYTE and Novocure. H.B.N. has been on advisory boards and speakers’ bureaus for Novocure Corporation and Caris Life Sciences and has been on the speakers’ bureau for Genentech. The remaining authors report no disclosures.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jnnonline.com).

Online date: June 7, 2019

© 2019 American Association of Neuroscience Nurses