International Consensus Recommendations for the Treatment of Pediatric NMDAR Antibody Encephalitis

Margherita Nosadini1, Terrence Thomas1, Michael Eyre1

  • 1From the Paediatric Neurology and Neurophysiology Unit (M.N.), Department of Women's and Children's Health, University Hospital of Padova; Neuroimmunology Group (M.N.), Paediatric Research Institute "Città della Speranza," Padova, Italy; Department of Paediatrics (T.T.), Neurology Service, KK Women's and Children's Hospital, Singapore; School of Biomedical Engineering & Imaging Sciences (M.E.), King's College London; Children's Neurosciences (M.E.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, United Kingdom; Department of Pediatric Neurology (B.A.), Hacettepe University, Ankara, Turkey; Neuroimmunology Program (T.A.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona; Pediatric Neuroimmunology Unit (T.A.), Neurology Department, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Spain; Alberta Children's Hospital Research Institute (S.M.B.), Department of Pediatrics, Cumming School of Medicine, University of Calgary; Division of Rheumatology (T.C.), Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Assistance Publique-Hôpitaux de Paris (K.D.), Pediatric Neurology Department, University Hospitals Paris Saclay, Bicêtre Hospital, France; French Reference Network of Rare Inflammatory Brain and Spinal Diseases (K.D.), Le Kremlin Bicêtre, France and European Reference Network-RITA; Departments of Neurology and Pediatrics (W.G.), Stanford University and Lucile Packard Children's Hospital, Palo Alto, CA; Division of Pediatric Neurology (G.G.), Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, GA; Department of Neurology (M.P.G.), Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Neuroinflammation (Y.H.), Queen Square MS Centre, UCL Institute of Neurology, University College London; Department of Paediatric Neurology (Y.H.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Pediatrics (Y.J.), Peking University First Hospital, Beijing, China; Department of Pediatrics (B.C.L.), Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea; Department of Pediatrics (E.M.), Section Rheumatology, Co-appointment in the Section of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston; Division of Paediatric Neurology (A.N.), Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town; Faculty of Health Sciences (A.N.), University of Cape Town Neuroscience Institute, South Africa; Department of Neurology (R.N.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Pediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Germany; Department of Brain and Neural Science (H.S.), Tokyo Metropolitan Institute of Medical Science, Japan; Department of Pediatrics (Neurology Division) (S.S.), Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India; Department of Neurology (S.N.T.), National Pediatric Hospital Dr. J. Garrahan, Buenos Aires, Argentina; Department of Pediatrics (H.A.V.M.), Duke University, Durham, NC; Department of Neurology (E.W.), Children's National Medical Center, Washington, DC; Neuropaediatric Unit (R.W.), Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (A.K.Y.), Icahn School of Medicine at Mount Sinai, New York; Oxford Autoimmune Neurology Group (S.R.I.), Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital; Department of Neurology (S.R.I.), Oxford University Hospitals NHS Foundation Trust, United Kingdom; Neuroimmunology Program (J.D.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain; Children's Neurosciences (M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust; King's Health Partners Academic Health Science Centre (M.L.); Faculty of Life Sciences and Medicine (M.L.), King's College Hospital, United Kingdom; and Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia.

Insights

International guidelines recommend corticosteroids for pediatric NMDA receptor antibody encephalitis (NMDARE). Severe cases may need IV immunoglobulin or plasma exchange, with rituximab preferred for refractory conditions.

Area of Science:

  • Neurology
  • Immunology
  • Pediatrics

Background:

  • Pediatric NMDA receptor antibody encephalitis (NMDARE) is a severe autoimmune neurological disorder.
  • Standardized international treatment guidelines are lacking, leading to variable clinical management.

Purpose of the Study:

  • To establish international consensus-based treatment recommendations for pediatric NMDARE.
  • To define key aspects of NMDARE management, including disease severity, treatment failure, and relapse.

Main Methods:

  • A 2-step Delphi method involving 27 international experts.
  • Consensus development through online meetings with a ≥75% agreement threshold.

Main Results:

  • Corticosteroids are recommended for all pediatric NMDARE cases, with IV immunoglobulin or plasma exchange for severe presentations.
  • First-line immunotherapy duration varies (3-12 months) based on severity; rituximab is preferred over cyclophosphamide for refractory cases.
  • Treatment duration and maintenance strategies are guided by disease severity and clinical course, with specific recommendations for relapsing and post-herpes simplex encephalitis NMDARE.

Conclusions:

  • These consensus recommendations aim to standardize pediatric NMDARE management and offer practical clinical guidance.
  • The guidelines may also be applicable to adult NMDARE cases.
Abstract