title: Gait Disturbance as the Presenting Symptom in Young Children With Anti-NMDA Receptor Encephalitis.
abstract: This case series demonstrates a novel clinical phenotype of gait disturbance as an initial symptom in children <3 years old with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. Anti-NMDAR encephalitis is one of the most common causes of encephalitis in children, more common than any of the viral encephalitides and the second most common autoimmune cause after acute disseminated encephalomyelitis. Anti-NMDAR encephalitis in children often presents with disrupted speech and sleep patterns followed by progression to motor dysfunction, dyskinesias, and seizures. Because this condition can present initially with vague symptoms, diagnosis and treatment of anti-NMDAR encephalitis are often delayed. Although nearly 40% of all reported patients are <18 years old, few infants and toddlers have been reported with this disease. Four children <3 years old were diagnosed with anti-NMDAR encephalitis at our institution. Interestingly, each child presented initially with the chief concern of gait disturbance. One child presented with unsteady walking and slurred speech, suggestive of cerebellar ataxia, and 3 had inability to bear weight on a unilateral lower extremity, resulting in unsteady gait. Two of these children had seizures at the time of hospital presentation. All developed classic behavioral changes, insomnia, dyskinesias, or decreased speech immediately before or during hospitalization. When seen in the setting of other neurologic abnormalities, gait disturbance should raise the concern for anti-NMDAR encephalitis in young children. The differential diagnosis for gait disturbance in toddlers and key features suggestive of anti-NMDAR encephalitis are reviewed.
authors.affiliation: Division of Pediatric Neurology, and ayeshok1@jhmi.edu.
authors.forename: Anusha K
authors.initials: AK
authors.lastname: Yeshokumar
authors.affiliation: Division of Pediatric Neurology, and.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Sun
authors.affiliation: Division of Pediatric Neurology, and Department of Pediatrics, The Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Klein
authors.affiliation: Division of Pediatric Neurology, and.
authors.forename: Kristin W
authors.initials: KW
authors.lastname: Baranano
authors.affiliation: Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Pardo
mesh_terms: D060426:Anti-N-Methyl-D-Aspartate Receptor Encephalitis / Q000175:diagnosis* / Q000188:drug therapy; D000906:Antibodies / Q000134:cerebrospinal fluid; D001921:Brain / Q000000981:diagnostic imaging; D002675:Child, Preschool; D020820:Dyskinesias / Q000209:etiology; D005260:Female; D020233:Gait Disorders, Neurologic / Q000209:etiology*; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use; D016194:Receptors, N-Methyl-D-Aspartate / Q000276:immunology; D012640:Seizures / Q000209:etiology; D007319:Sleep Initiation and Maintenance Disorders / Q000209:etiology; D013064:Speech Disorders / Q000209:etiology
chemical_list: D000906:Antibodies; D005938:Glucocorticoids; D016756:Immunoglobulins, Intravenous; D016194:Receptors, N-Methyl-D-Aspartate; D008775:Methylprednisolone