Casiraghi et al. assessments), viral [antibody-specific index (AI) for herpes-simplex computer virus, varicella zoster computer virus, Epstein-Barr computer virus (EBV), measles computer virus, and rubella computer virus; polymerase-chain-reaction (PCR) for DNA of herpes-simplex computer virus, varicella zoster computer virus, EpsteinCBarr computer virus, entero-virus, parecho-virus, adeno-virus, JC-virus, and human herpesvirus-6], and fungal (cultural growth and antigen test to Aspergillus and Exemplary axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) of the brain exhibited leukoencephalopathy but no indicators of inflammation. Immune-fluorescence microscopy of anti-NMDA receptor staining with high ( em B1 /em ) and low titers ( em B2 /em ) in serum (depicted) and CSF. Bright green cells represent an antibody-antigen-interaction ( em B1 /em ) while dim cells do not reveal such conversation ( em B2 /em ). CSF, cerebrospinal fluid; MRI, magnetic resonance imaging; MP, methylprednisolone; IA, immunoadsorption-therapy; IG, intravenous immunoglobulins; RTX, rituximab; CP, cyclophosphamide; Anti-NMDA receptor, Anti-N-methyl-D-aspartate receptor. Additionally, flow cytometry of the CSF was performed to exclude post-transplant lymphoproliferative disorders (9, 10). Corticoid treatment with 1 g of intravenous methylprednisolone was administered for 5 days followed by five courses of immunoadsorption therapy. The patient’s symptoms did not improve and thus a therapy with two cycles of intravenous immunoglobulins (60 g in total) was performed followed by a second course of methylprednisolone (1 g daily for 5 days) and two applications of rituximab (2 1,000 mg within 14 days). Because of the devastating disease course without any improvement, an additional immunosuppressive therapy with cyclophosphamide (750 mg/m2) was performed. White blood cell populace count after extended immunosuppressive therapy revealed a decrease of leukocytes (2,400/l) and lymphocytes (700/l). As the patient experienced further epileptic seizures, the anticonvulsive treatment was expanded with valproate and lacosamid. Due to persisting epileptic seizures, lacosamid was changed to phenytoin. Meanwhile, the gynecologic diagnostic including ovarian ultrasound remained unremarkable. Whole-body PET-CT screening showed no indicators of a paraneoplastic etiology of the autoimmune encephalitis. Nevertheless, the patient underwent oophorectomy of both sides, as a rescue option Bis-NH2-C1-PEG3 that can be considered in imaging-negative anti-NMDA receptor encephalitis patients without obvious ovarian teratoma (11). Histological examination of the ovarian tissue did not detect a teratoma. In the course of the disease, the patient slightly regained consciousness. Follow-up CSF diagnostic 8 weeks after first symptoms and 5 weeks after the first dose of steroids showed decreasing pleocytosis (10 cells/l, thereof 90% lymphocytes and 10% monocytes) and reduced anti-NMDAR-IgG antibodies titers (1:100 in serum, 1:50 in CSF, Physique 1, em B2 /em ). The immunosuppressive therapy was switched back to oral treatment with tacrolimus and mycophenolate mofetil and the patient was transferred to a rehab facility. The patient regained consciousness and orientation but showed a reduced general condition with cachexia and was not able to walk. After 6 weeks, she was readmitted to our hospital for another course of cyclophosphamide and after 6 months for rituximab treatment. In the course, repeated tumor screening including cerebral, abdominal, and thoracic imaging Bis-NH2-C1-PEG3 showed no evidence of concomitant malignant diseases. However, the patient did not fully recover and died 2 years after disease onset due to septicemia (see timeline physique for overview). Discussion Here, we present the first case Bis-NH2-C1-PEG3 of anti-NMDA receptor encephalitis developing despite immunosuppressive therapy after liver transplantation. Mycophenolate mofetil and tacrolimus are both highly effective drugs and were developed to prevent autoimmunity in patients after transplantation of solid organs (12C14). Mycophenolate mofetil has inhibitory effects on B- and T-cells, while tacrolimus reduces activation of T-cells (14, 15). Since the pathomechanisms of anti-NMDA receptor encephalitis are considered to be driven by complement-independent antibody effects, it could be assumed that this autoimmune disease should not occur under adequate immunosuppressive therapy with mycophenolate mofetil and tacrolimus (7). However, similar cases have been described in three patients after kidney transplantation (4, 5, Rabbit Polyclonal to NDUFS5 8), in one patient after repeated stem-cell transplantations in childhood and kidney transplantation in the course (7), and in one patient after heart transplantation (6). In all five published cases, immunosuppressive therapy at the time of encephalitis onset consisted of mycophenolate mofetil in addition to either tacrolimus or prednisolone (4C8). Furthermore, several reports showed that patients after allogeneic or autologous stem cell transplantation developed autoimmune diseases such as polymyositis, myasthenia gravis, GuillainCBarr syndrome, and anti-LGI1 and anti-GABAAR encephalitis, concluding that this inhibitory effect.