Recoverin-Positive Encephalitis Treatment
Immediate Critical Care and Immunotherapy
Recoverin-positive encephalitis requires urgent immunosuppressive therapy with high-dose intravenous corticosteroids as first-line treatment, given its autoimmune paraneoplastic nature, with consideration for plasma exchange or intravenous immunoglobulin if corticosteroids fail. 1, 2
Acute Management Priorities
Transfer to intensive care immediately if consciousness is declining, as autoimmune encephalitis can cause rapid deterioration requiring airway protection, ventilatory support, intracranial pressure management, and cerebral perfusion optimization. 3, 2
Obtain neurological specialist assessment within 24 hours of presentation to optimize morbidity and mortality outcomes. 1, 2
Initiate high-dose intravenous methylprednisolone (typically 1 gram daily for 3-5 days) as first-line immunotherapy for autoimmune encephalitis without waiting for confirmatory antibody results if clinical suspicion is high. 1, 2
Diagnostic Workup
Obtain MRI brain within 48 hours as it detects early cerebral changes in approximately 90% of encephalitis cases versus only 25% sensitivity for CT. 1, 2
Perform lumbar puncture with comprehensive CSF analysis including cell count, protein, glucose, and PCR for HSV-1/2, VZV, and enteroviruses to exclude infectious etiologies that would contraindicate immunosuppression. 3, 1
Send serum and CSF for recoverin antibodies and comprehensive paraneoplastic/autoimmune encephalitis panel, though treatment should not be delayed awaiting results. 4, 5
Obtain EEG when distinguishing psychiatric versus organic causes or when subtle seizures are suspected (abnormal in >80% of encephalitis cases). 1, 2
Escalation of Immunotherapy
If no improvement occurs within 5-7 days of high-dose corticosteroids:
Consider plasma exchange as second-line therapy for autoimmune encephalitis, particularly effective in antibody-mediated conditions like recoverin-positive encephalitis. 1
Alternatively, administer intravenous immunoglobulin (typically 2 g/kg divided over 2-5 days) as second-line immunotherapy. 3, 1
Paraneoplastic Evaluation
Recoverin antibodies are strongly associated with cancer-associated retinopathy and paraneoplastic encephalitis, most commonly small cell lung cancer:
Perform urgent CT chest/abdomen/pelvis to screen for underlying malignancy, as treating the primary tumor is essential for long-term neurological recovery. 4, 6
Consider PET-CT if initial imaging is negative, as identifying and treating the underlying malignancy is critical for preventing progression. 6
Seizure Management
If seizures occur during acute illness:
Use IV valproate 20-30 mg/kg loading dose (88% seizure cessation within 20 minutes without hypotension). 2
Alternatively, use levetiracetam 30-60 mg/kg/day (73% seizure cessation rate). 2
Avoid phenytoin as first-line (only 56% efficacy and causes hypotension in 12% of cases). 2
Critical Pitfalls to Avoid
Do not delay immunotherapy while awaiting antibody confirmation, as recoverin-positive encephalitis can cause irreversible neurological damage if treatment is delayed. 4, 5, 6
Do not use corticosteroids if infectious encephalitis has not been excluded, particularly HSV encephalitis, which would require acyclovir rather than immunosuppression. 7, 5, 8
Do not discharge without comprehensive rehabilitation assessment, as 30-50% develop long-term neurological or psychiatric sequelae including anxiety, depression, obsessive behaviors, and cognitive deficits. 3, 1, 2
Discharge Planning and Long-Term Management
Arrange outpatient follow-up before discharge with definite or suspected diagnosis documented, and formulate plans for ongoing immunotherapy taper and rehabilitation. 3, 1
Ensure access to comprehensive rehabilitation including neuropsychology, speech and language therapy, neurophysiotherapy, and occupational therapy, as sequelae may not be immediately apparent at discharge. 3, 1
Monitor for tumor recurrence with serial imaging every 3-6 months if paraneoplastic etiology confirmed, as neurological symptoms may herald cancer relapse. 6
Provide information about support organizations such as the Encephalitis Society to reduce isolation and help family adjustment. 3