What is the initial treatment for a 60-year-old patient diagnosed with autoimmune limbic encephalitis?

From the Guidelines

The initial treatment for a 60-year-old patient diagnosed with autoimmune limbic encephalitis should involve first-line immunotherapy with high-dose corticosteroids, such as methylprednisolone 1000 mg IV daily for 3-5 days, followed by oral prednisone 1 mg/kg/day with a slow taper over 2-3 months, as recommended by the most recent guidelines 1. This approach is supported by the proposed best practice recommendations for diagnosis and acute management of autoimmune encephalitis, which suggest that corticosteroids alone or combined with other agents (intravenous IG or plasmapheresis) are the preferred first-line therapy for patients with a general presentation 1. The treatment should be initiated as soon as possible after diagnosis, as early intervention is associated with better outcomes. Some key points to consider in the management of autoimmune limbic encephalitis include:

• Evaluating the likelihood of autoimmune encephalitis relative to the patient’s clinical picture
• Performing brain MRI and/or EEG to look for focal or multifocal brain abnormality
• Performing lumbar puncture to support inflammatory aetiology and rule out infective/neoplastic causes
• Sending blood tests to rule out other potential causes guided by neuroanatomical and clinical data
• Considering brain FDG-PET when there is a high clinical suspicion of autoimmune encephalitis and other paraclinical studies are uninformative
• Performing cancer screening with CT chest, abdomen, and pelvis with contrast in relevant cases Supportive care is also essential, including:
• Seizure management with antiepileptic drugs if needed
• Addressing psychiatric symptoms that may occur
• Tumor screening, as many cases are paraneoplastic, particularly in this age group If a tumor is identified, its removal is a priority. Second-line therapies, such as rituximab or cyclophosphamide, may be considered if the patient doesn't respond adequately to first-line treatments 1.

From the Research

Initial Treatment for Autoimmune Limbic Encephalitis

The initial treatment for a 60-year-old patient diagnosed with autoimmune limbic encephalitis typically involves immunotherapy.

• First-line treatments include:
  • Intravenous steroids
  • Intravenous immunoglobulins (IVIG)
  • Plasma exchange 2, 3, 4
• These treatments can be combined in severe cases and are usually prescribed once a diagnosis of possible autoimmune encephalitis is established.

Second-Line Therapies

For patients who do not respond to first-line treatments, second-line therapies may be considered.

• These include:
  • Rituximab
  • Cyclophosphamide 2, 3, 4, 5
• Alternative therapies, such as tocilizumab and bortezomib, may also be used in refractory cases 2, 4, 5.

Considerations for Treatment

The treatment approach may vary depending on the patient's specific condition, including the presence of seizures or other symptoms.

• Antiepileptic treatment may be necessary for patients with seizures 3.
• Evaluation and treatment of any underlying cancer may also be required, particularly in cases of paraneoplastic encephalitis 3.
• The duration of maintenance therapy is uncertain, but it is typically recommended to continue treatment for 3-5 years before discontinuing immunotherapy 3.