title: Possible autoimmune association between herpes simplex virus infection and subsequent anti-N-methyl-d-aspartate receptor encephalitis: a pediatric patient with abnormal movements.
abstract: OBJECTIVE
  We describe a child with severe generalized choreoathetosis and anti-N-methyl-d-aspartate receptor encephalitis after herpes simplex virus type 1 encephalitis. Recent evidence supports an autoimmune trigger for anti-N-methyl-d-aspartate receptor encephalitis following a viral infection. This is emerging as a common and potentially treatable autoimmune condition in the pediatric population.
  
  
  METHODS
  A 6-month-old girl presented with fever, diarrhea, and partial seizures and was subsequently treated for proven herpes simplex virus type 1 encephalitis. Shortly thereafter, she developed irritability, insomnia, dysautonomia, orolingual and facial choreodystonic movements, spontaneous vocalizations, and choreoathetoid movements of her trunk and limbs. Cerebrospinal fluid analysis confirmed anti-N-methyl-d-aspartate receptor antibodies. Management of her movements required titrated doses of clobazam, valproate, tetrabenazine, and immunotherapy. At 3 months' follow-up, her abnormal movements had completely resolved.
  
  
  CONCLUSIONS
  Our patient adds to recent evidence linking a viral trigger for brain autoimmunity. Movement disorders appear early, leading to severe patient and family distress, and pose a serious management dilemma because of a paucity of clinical trials assessing treatments in the pediatric population. Abnormal hyperkinetic movements present early and prominently, requiring a combination of symptomatic and immune-modulating therapies for successful treatment.
authors: Department of Neurology, Albany Medical College, Albany, New York. Electronic address: yushvay@mail.amc.edu.
authors: Yefim
authors: Y
authors: Yushvayev-Cavalier
authors: Division of Pediatric Neurology, Department of Neurology, Albany Medical College, Albany, New York.
authors: Charles
authors: C
authors: Nichter
authors: Division of Movement Disorders, Department of Neurology, Albany Medical College, Albany, New York.
authors: Adolfo
authors: A
authors: Ramirez-Zamora
mesh_terms: D060426:Anti-N-Methyl-D-Aspartate Receptor Encephalitis / Q000188:drug therapy / Q000473:pathology / Q000503:physiopathology*; D001921:Brain / Q000473:pathology; D020820:Dyskinesias / Q000188:drug therapy / Q000473:pathology / Q000503:physiopathology*; D020803:Encephalitis, Herpes Simplex / Q000473:pathology / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D018259:Herpesvirus 1, Human; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging
keywords: NMDA; dyskinesias; encephalitis; herpes simplex; rituximab; tetrabenazine