Plasmafaresis pada Pasien Status Epileptikus Akibat Ensefalitis Anti-NMDAR di Unit Perawatan Intensif

Abstract

Sejak tahun 2007 penyebab lain ensefalitis diketahui adalah autoimmun selain virus sebagai penyebab terbanyak (69%) dengan angka kematian di dunia 8–18,45%. Ensefalitis anti-NMDAR adalah ensefalitis autoimun akibat reaksi antibodi terhadap antigen membran ekstraseluler, subunit NR1, yaitu reseptor glutamat NMDA di sinapsis susunan saraf pusat. Kasus ensefalitis NMDAR sangat jarang dijumpai, berdasarkan penelitian yang teridentifikasi hanya 1% pasien usia 18–35 tahun yang dirawat di Unit Perawatan Intensif (UPI), namun dengan penatalaksanaan yang tepat dapat meningkatkan prognosis pasien. Pasien laki-laki, usia 36 tahun dikonsulkan ke UPI RSHS setelah 10 hari rawatan di Neuro High Care (NHC) pada bulan Agustus 2019 dengan penurunan kesadaran disertai riwayat kejang berulang dengan diagnosis ensefalitis anti-NMDAR. Kombinasi obat anti-viral, anti-epilepsi, dan metilprednisolon yang diberikan sebelumnya di ruangan tidak memberikan perbaikan klinis bermakna. Selama perawatan di UPI pasien diberikan terapi plasmafaresis dan menunjukkan perbaikan secara signifikan. Bangkitan kejang berulang dapat berupa kejang parsial, kejang generalisata dan status epileptikus. Manifestasi kejang diduga terjadi karena terbentuknya antibodi yang menyerang reseptor glutamat NMDA dengan target utama NR1. The American Society for Apheresis merekomendasikan plasmaferesis sebagai pilihan terapi utama. Simpulan, terapi plasmafaresis dalam tata laksana kasus ensefalitis anti- NMDAR merupakan pilihan tepat karena terbukti efektif dan efisien dalam perbaikan klinis pasien melalui mekanisme penurunan titer antibodi terhadap reseptor NMDA.

Plasmapheresis in Patients of Epilepticus Status Patients Due to
Anti-NMDAR Encephalitis in Intensive Care Units

Since 2007 another known cause of encephalitis is autoimmune other than viruses as the most common cause (69%) with a mortality rate in the world of 8-18.45%. Anti-NMDAR encephalitis (n-Methyl-D-Aspartate receptor) is an autoimmune encephalitis due to an antibody reaction to the extracellular membrane antigen, NR1 subunit, the NMDA glutamate receptor at the synapses of the central nervous system. Cases of NMDAR encephalitis are very rare, based on studies that identified only 1% of patients aged 18-35 years who were treated in the Intensive Care Unit (ICU), but with proper management could improve the patient's prognosis.

Male patient, 36 years old, was admitted to ICU RSHS after 10 days of treatment at Neuro High Care (NHC) in August 2019 with decreased consciousness accompanied by a history of recurrent seizures with a diagnosis of anti-NMDAR encephalitis. The combination of anti-viral, anti-epileptic, and methylprednisolone drugs given previously at NHC did not provide clinically meaningful improvement. During treatment at ICU, patients were given plasmafaresis therapy and showed significant improvement. Recurrent seizures can be partial seizures, generalized seizures and status epilepticus. Seizure manifestations are thought to occur due to the formation of antibodies that attack NMDA glutamate receptors with the main target NR1. The American Society for Apheresis recommends plasmapheresis as the main therapeutic choice. In conclusion, plasmafaresis therapy in the management of anti-NMDAR encephalitis cases is the right choice because it is proven effective and efficient in the clinical improvement of patients through the mechanism of decreasing antibody titers to NMDA receptors.