Articles

Frequency, symptoms, risk factors, and outcomes of

autoimmune encephalitis after herpes simplex
encephalitis: a prospective observational study and
retrospective analysis
Thaís Armangue, Marianna Spatola, Alexandru Vlagea, Simone Mattozzi, Marc Cárceles-Cordon, Eloy Martinez-Heras, Sara Llufriu, Jordi Muchart,
María Elena Erro, Laura Abraira, German Moris, Luis Monros-Giménez, Íñigo Corral-Corral, Carmen Montejo, Manuel Toledo, Luis Bataller,
Gabriela Secondi, Helena Ariño, Eugenia Martínez-Hernández, Manel Juan, Maria Angeles Marcos, Laia Alsina, Albert Saiz, Myrna R Rosenfeld,
Francesc Graus, Josep Dalmau, on behalf of the Spanish Herpes Simplex Encephalitis Study Group*

Summary
Background Herpes simplex encephalitis can trigger autoimmune encephalitis that leads to neurological worsening. Lancet Neurol 2018
We aimed to assess the frequency, symptoms, risk factors, and outcomes of this complication. Published Online
July 23, 2018
http://dx.doi.org/10.1016/
Methods We did a prospective observational study and retrospective analysis. In the prospective observational part of
S1474-4422(18)30244-8
this study, we included patients with herpes simplex encephalitis diagnosed by neurologists, paediatricians, or
See Online/Comment
infectious disease specialists in 19 secondary and tertiary Spanish centres (Cohort A). Outpatient follow-up was at 2, http://dx.doi.org/10.1016/
6, and 12 months from onset of herpes simplex encephalitis. We studied another group of patients retrospectively, S1474-4422(18)30279-5
when they developed autoimmune encephalitis after herpes simplex encephalitis (Cohort B). We compared *Study group members listed at
demographics and clinical features of patients who developed autoimmune encephalitis with those who did not, and end of the Article
in patients who developed autoimmune encephalitis we compared these features by age group (patients ≤4 years Neuroimmunology Program,
compared with patients >4 years). We also used multivariable binary logistic regression models to assess risk factors Institut d’Investigacions
Biomèdiques August Pi i
for autoimmune encephalitis after herpes simplex encephalitis. Sunyer (IDIBAPS)
(T Armangue MD, M Spatola MD,
Findings Between Jan 1, 2014, and Oct 31, 2017, 54 patients with herpes simplex encephalitis were recruited to S Mattozzi, MD,
Cohort A, and 51 were included in the analysis (median age 50 years [IQR 5–68]). At onset of herpes simplex M Cárceles-Cordon BS,
H Ariño MD,
encephalitis, none of the 51 patients had antibodies to neuronal antigens; during follow-up, 14 (27%) patients E Martínez-Hernández MD,
developed autoimmune encephalitis and all 14 (100%) had neuronal antibodies (nine [64%] had NMDA receptor A Saiz MD,
[NMDAR] antibodies and five [36%] had other antibodies) at or before onset of symptoms. The other 37 patients Prof M R Rosenfeld MD,
did not develop autoimmune encephalitis, although 11 (30%) developed antibodies (n=3 to NMDAR, n=8 to Prof F Graus MD,
Prof J Dalmau MD), Laboratory
unknown antigens; p<0·001). Antibody detection within 3 weeks of herpes simplex encephalitis was a risk factor of Advanced Imaging in
for autoimmune encephalitis (odds ratio [OR] 11·5, 95% CI 2·7–48·8; p<0·001). Between Oct 7, 2011, and Neuroimmunological Diseases
Oct 31, 2017, there were 48 patients in Cohort B with new-onset or worsening neurological symptoms not caused (IDIBAPS)
by herpes simplex virus reactivation (median age 8·8 years [IQR 1·1–44·2]; n=27 male); 44 (92%) patients had (E Martinez-Heras PhD,
S Llufriu MD), Service of
antibody-confirmed autoimmune encephalitis (34 had NMDAR antibodies and ten had other antibodies). In both Neurology (S Llufriu,
cohorts (n=58 patients with antibody-confirmed autoimmune encephalitis), patients older than 4 years frequently C Montejo MD, A Saiz,
presented with psychosis (18 [58%] of 31; younger children not assessable). Compared with patients older than Prof F Graus, Prof J Dalmau),
Immunology Department,
4 years, patients aged 4 years or younger (n=27) were more likely to have shorter intervals between onset of herpes
Centre of Biomedical Diagnosis
simplex encephalitis and onset of autoimmune encephalitis (median 26 days [IQR 24–32] vs 43 days [25–54]; (A Vlagea MD, M Juan MD), and
p=0·0073), choreoathetosis (27 [100%] of 27 vs 0 of 31; p<0·001), decreased level of consciousness (26 [96%] of Microbiology Department
27 vs seven [23%] of 31; p<0·001), NMDAR antibodies (24 [89%] of 27 vs 19 [61%] of 31; p=0·033), and worse (M A Marcos MD), Hospital
Clínic, University of Barcelona,
outcome at 1 year (median modified Rankin Scale 4 [IQR 4–4] vs 2 [2–3]; p<0·0010; seizures 12 [63%] of 19 vs
Barcelona, Spain; Pediatric
three [13%] of 23; p=0·001). Neuroimmunology Unit,
Neurology Department
Interpretation The results of our prospective study show that autoimmune encephalitis occurred in 27% of patients (T Armangue, G Secondi MD),
Department of Radiology
with herpes simplex encephalitis. It was associated with development of neuronal antibodies and usually presented
(J Muchart MD), and Functional
within 2 months after treatment of herpes simplex encephalitis; the symptoms were age-dependent, and the Unit of Clinical Immunology
neurological outcome was worse in young children. Prompt diagnosis is important because patients, primarily those (A Vlagea, M Juan, L Alsina MD),
older than 4 years, can respond to immunotherapy. Research Institute of Sant Joan
de Déu Children’s Hospital,
University of Barcelona,
Funding Mutua Madrileña Foundation, Fondation de l’Université de Lausanne et Centre Hospitalier Universitaire Barcelona, Spain; University of
Vaudois, Instituto Carlos III, CIBERER, National Institutes of Health, Generalitat de Catalunya, Fundació CELLEX. Lausanne, Lausanne,
Switzerland (M Spatola);
Section of Child
Copyright © 2018 Elsevier Ltd. All rights reserved.

www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8 1

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Neuropsychiatry, Department
of Medical Surgical and
Experimental Medicine,
University of Sassari (Sassari),
Italy (S Mattozzi); Department
of Neurology, Complejo
Hospitalario de Navarra,
Pamplona, Spain (M E Erro MD);
Department of Neurology,
Hospital Vall d’Hebron,
Barcelona, Spain (L Abraira MD,
M Toledo MD); Department of
Neurology, Hospital Central de
Asturias, Oviedo, Spain
(G Moris MD); Department of
Neurology, Hospital
Universitari i Politècnic La Fe,
Valencia, Spain
(L Monros-Giménez MD,
L Bataller MD); Hospital
Universitario Ramon y Cajal,
Madrid, Spain
(Í Corral-Corral MD);
Department of Neurology,
University of Pennsylvania, PA,
USA (Prof M R Rosenfeld,
Prof J Dalmau); and Catalan
Institution for Research and
Advanced Studies (ICREA),
Barcelona, Spain (Prof J Dalmau)
Correspondence to:
Prof Josep Dalmau,
IDIBAPS-CELLEX, Casanova 143,
Barcelona 08036, Spain
jdalmau@clinic.cat
Research in context
Evidence before this study
Some patients with herpes simplex encephalitis develop
neurological relapses a few weeks after successful treatment of
the viral infection, but the frequency of this complication,
spectrum of symptoms, risk factors, and prognosis are largely
unknown. Autoimmune mechanisms were considered to be
responsible, but the evidence was circumstantial and the target
antigens unknown. These targets were recently identified as the
NMDA receptor (NMDAR) and other neurotransmitter
receptors. We searched MEDLINE and Embase for articles
published in English before April 1, 2018, using the MeSH terms
“herpes simplex encephalitis”, “relapsing encephalitis”,
“post-herpes simplex encephalitis”, “choreoathetosis”, “NMDA
receptor antibodies”, or “N-methyl-d-aspartate receptor
antibodies”. We restricted searches to human studies. We also
reviewed the reference lists of the papers identified by this
search.
Added value of this study
In this study, we describe the frequency, clinical features, risk
factors, and prognosis of autoimmune encephalitis after herpes
simplex encephalitis in two cohorts of patients. Cohort A is a
prospective multicentre study of patients diagnosed with
herpes simplex encephalitis. Cohort B is a retrospective study of
patients who developed neurological worsening after herpes
simplex encephalitis. The findings show that autoimmune
encephalitis after herpes simplex encephalitis is frequent, and
that the associated symptoms vary with patients’ age. Children
aged 4 years or younger were more likely to develop
choreoathetosis, impaired level of consciousness, and refractory
seizures (often with infantile spasms) than were patients older
than 4 years. Older children and adults were more likely to
present with cognitive changes and psychiatric symptoms. The
symptoms in younger children (≤4 years) correspond to that
previously known as choreoathetosis after herpes simplex
encephalitis, but the frequent presence of infantile spasms had
not been previously reported. The clinical features in older
children and adults were less known, and we show that
psychosis is a frequent symptom presentation in this group
(mainly if NMDAR antibodies are present). The main risk factor
for autoimmune encephalitis after herpes simplex encephalitis
was the detection of autoantibodies (against NMDAR or
unknown cell-surface antigens) at follow-up 3 weeks after
diagnosis of herpes simplex encephalitis. The neurological
outcome was worse in children aged 4 years or younger, as
indicated by worse mean modified Rankin Scale scores and
greater number of seizures at 1 year.
Implications of all the available evidence
Findings from this study should raise awareness for
autoimmune encephalitis after herpes simplex encephalitis.
Detection of antibodies to NMDAR and other neurotransmitter
receptors 3 weeks after the diagnosis of herpes simplex
encephalitis is associated with the development of autoimmune
encephalitis. Prompt recognition of this complication is
important because patients, mainly older children and adults,
respond better to immunotherapy.

Introduction receptors (such as the NMDA receptor [NMDAR]) and

Herpes simplex virus encephalitis is the most frequent
cause of sporadic infectious encephalitis in high-income
countries, with a worldwide incidence of two to four cases
per million people each year.1 It affects patients of either
sex, with a bimodal age distribution in which children and
elderly people are the most frequently and severely
affected. The fatality rate among patients treated with
aciclovir is 10–25%, and 40–55% of surviving patients are
able to resume activities of daily living.2 A separate
problem is the development of neurological relapses or
worsening of deficits, which have been reported in 5–26%
of cases.3–6 These complications tend to occur within the
first 2 months of completing treatment with aciclovir and
can affect children and adults. In some patients, the
symptoms of relapse are caused by reactivation or
persistence of the herpes simplex virus, as shown by
detection of viral DNA in CSF,6 but in many cases viral
testing is negative and treatment with aciclovir is
ineffective. The observation that symptoms can improve
or stabilise after treatment with steroids suggested that
inflammatory or immune mechanisms underlie some of
these compli­cations.5,6 This hypothesis has gained support
from reports describing IgG antibodies against synaptic
other neuronal surface proteins in serum or CSF from
patients with relapsing or worsening neurological
symptoms after herpes simplex encephalitis.7–14 In
preliminary studies, children with this type of autoimmune
encephalitis predominantly developed choreoathetosis—a
previously known late complication of herpes simplex
encephalitis15—whereas adults dev­eloped psychiatric and
cognitive deficits.8,16 It has been reported that
immunotherapy is effective in this type of autoimmune
encephalitis, but most of the findings are based on small,
retrospective case series in which patients were selected
for autoantibody testing.7–11 In this study, we aimed to
investigate some of the outstanding questions related to
relapsing symptoms after herpes simplex encephalitis,
including the frequency of these complications, main
clinical symptoms in children and adults, risk factors,
frequency of neuronal autoantibodies, response to
immunotherapy, and long-term neurological outcomes.
Methods
Study design and participants
We designed a prospective multicentre observational
study, in which patients with new-onset herpes simplex

2 www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8

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encephalitis were recruited in 19 participating centres in
Spain (appendix). All patients had herpes simplex
encephalitis as diagnosed by neurologists, paediatricians,
or infectious disease specialists, and confirmed with a
PCR of CSF positive for herpes simplex virus type 1
(HSV1) or type 2 (HSV2). We excluded patients from
Cohort A who died within the first 3 weeks of recruitment,
or who had an interval of more than 10 days between
symptom onset of herpes simplex encephalitis and
recruitment. Patients from Cohort B who had an interval
of more than 4 months between symptom onset of
autoimmune encephalitis and determination of serum
and CSF antibodies were excluded from the analysis.
Patients in both cohorts were considered to have
probable autoimmune encephalitis after herpes simplex
encephalitis if, within the first 12 months after complet­ing
treatment with aciclovir, they developed new-onset CNS
symptoms or worsening of pre-existing deficits that lasted
for more than 24 h, had a negative PCR of CSF for herpes
simplex virus, and the symptoms could not be explained
by other complications (eg, metabolic derangement, drug
toxicity, stroke) or residual lesions caused by the viral
encephalitis (eg, isolated new-onset epilepsy).
questionnaires on all patients suspected of having
autoimmune encephalitis after herpes simplex See Online for appendix
encephalitis. The serum and CSF of these patients were
analysed for autoantibodies at IDIBAPS-Hospital
Clinic, University of Barcelona, using the same
techniques as those used for samples from Cohort A.
These patients were studied while they had symptoms
of autoimmune encephalitis, meaning the only
retrospective information was about herpes simplex
encephalitis.
In Cohort A, we calculated the frequency and risk
factors for autoimmune encephalitis, compared the
clinical features of herpes simplex encephalitis between
patients who later developed autoimmune encephaltis
and those who did not, and examined the outcome of
both groups at 1-year follow-up. We derived the clinical
features and outcome of autoimmune encephalitis after
herpes simplex encephalitis from Cohorts A and B, and
additionally, we investigated whether the clinical
manifestations of patients with autoimmune encephalitis
varied according to the patient’s age.
Patients in both cohorts were started on a standard
dose of intravenous aciclovir (1500 mg/m² for patients

Procedures
Clinical information was obtained from treating physicians 54 patients with herpes simplex 53 patients with new-onset or
encephalitis (Cohort A) worsening symptoms after
in Cohort A with standardised questionnaires that were herpes simplex encephalitis
completed at different timepoints: at diagnosis of herpes (Cohort B)
simplex encephalitis; after discontinuing treatment with
aciclovir (approximately 21 days); and at 2-month, 6-month, 3 excluded 5 excluded
and 12-month follow-up from onset of herpes simplex 3 died in first 3 weeks 5 viral reactivation
encephalitis. During these timepoint follow-ups in
Cohort A, we assessed neurological function using the 51 included in analysis 48 included in analysis
modified Rankin Scale (mRS).17,18 Patients were considered 48 with 6 months of follow-up
to have a good outcome if the mRS score at the last follow- 2 died
1 did not have 6-month data
up was 0–2, and a bad outcome if the score was greater 40 with 1 year of follow-up
than 2. Brain MRI scans were obtained at the discretion of 1 died
1 lost to follow-up
the treating clinician at diagnosis and were centrally 6 did not have 1-year data
reviewed at Institut d’Investigacions Biomèdiques August
Pi i Sunyer (IDIBAPS)-Hospital Clinic, University of
Barcelona, Barcelona, Spain (appendix). IgG antibodies
against NMDAR and other neuronal surface proteins were 14 with neurological 37 neurological
complications not due improvement or
determined in serum and CSF obtained at diagnosis and to viral reactivation stable deficits*
after completing aciclovir, and in serum obtained at follow- 3 died
up at 2, 6, and 12 months; these tests were done at
IDIBAPS-Hospital Clinic, University of Barcelona, with 14 with neuronal surface 44 with neuronal surface 4 no neuronal surface
previously reported techniques (appendix).19,20 Investigators antibodies antibodies antibodies
doing the autoantibody testing were masked to clinical 9 NMDAR 34 NMDAR
5 unknown antigens 10 unknown antigens
information, and the treating physicians were masked to
antibody results unless patients developed new neuro­
logical symptoms or unexplained progression of previous
deficits; if this occurred, new paired CSF and serum 58 with antibody-confirmed autoimmune encephalitis
after herpes simplex encephalitis
samples were examined and the results, along with those 43 NMDAR
of previous samples, were provided to the treating 15 unknown antigens
physician.
We obtained clinical information from treating Figure 1: Study profile
physicians in Cohort B using the indicated NMDAR=NMDA receptor. *11 with neuronal surface antibodies (n=3 NMDAR, n=8 unknown antigens).

www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8 3

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Statistical analysis
All (N=51) Autoimmune encephalitis Comparison*
after herpes simplex We used the Fisher exact test or Wilcoxon rank-sum
encephalitis test, as appropriate, to analyse the demographics and
Yes (n=14) No (n=37) clinical features of patients who developed autoimmune
encephalitis compared with those who did not develop
Median age, years 50 (5–68) 24 (0·9–75) 51 (13–68) p=0·290
autoimmune encephalitis or these features according to
Younger children (≤4 years) 13 (25%) 6 (43%) 7 (19%) p=0·089
age group (patients ≤4 years compared with patients
Older children (5–17 years) 5 (10%) 1 (7%) 4 (11%) p=0·182
>4 years). Multivariate binary logistic regression models
Adults (≥18 years) 33 (65%) 7 (50%) 26 (70%) p=0·182
were explored to identify predictor variables of developing
Sex
autoimmune encephalitis after herpes simplex
Women 22 (43%) 6 (43%) 16 (43%) p=0·980
encephalitis. All variables with a cutoff p value of less
Men 29 (57%) 8 (57%) 21 (57%) p=0·980
than 0·1 (likelihood ratio test) in univariate binary
Symptoms during herpes simplex encephalitis logistic models and clinically meaningful variables
Fever 49 (96%) 13 (93%) 36 (97%) p=0·490 (patients’ age, % volume involvement on MRI, CSF
Altered consciousness 35 (69%) 11 (79%) 24 (65%) p=0·335 pleocytosis, and protein concentration at 21 days) were
Abnormal behaviour 21 (41%) 5 (36%) 16 (43%) p=0·624 considered for the multivariate binary logistic regression
Memory deficits† 26/36 (72%) 6/8 (75%) 20/28 (71%) p=0·841 models, and approached by forward stepwise procedure
Aphasia† 28/36 (78%) 7/8 (88%) 21/28 (75%) p=0·431 (appendix). We also explored first-order interactions
Seizures 32 (63%) 11 (79%) 21 (57%) p=0·139 between variables. We used odds ratios (ORs) and
Motor deficit 21 (41%) 8 (57%) 13 (35%) p=0·156 95% CIs to measure the effect of predictors and adjusted
CSF at diagnosis of herpes simplex encephalitis for relevant variables if there was a clinically relevant
Median white blood cell count per mm3 77 (22–170) 77 (22–122) 77 (22–190) p=0·545 change in the OR.21,22 In all analyses, we applied a bilateral
Median protein concentration, mg/dL 60 (38–78) 62 (37–74) 57 (38–82) p=0·872 type I error of 5% without a formal correction for
Brain MRI abnormalities at diagnosis of herpes simplex encephalitis‡ multiplicity. We used STATA (version 13.1) for the
FLAIR, mean % lesion volume 3·9% (3·3) 4·5% (3·9) 3·4% (2·9) p=0·344 statistical analyses.
DWI, mean % lesion volume 3·7% (3·3) 3·6% (2·9) 3·8% (3·6) p=0·904
Contrast enhancement 21/34 (62%) 6/8 (75%) 15/26 (58%) p=0·368 Role of the funding source
Treatment of herpes simplex encephalitis The funders of the study had no role in study design,
Median time to start aciclovir, days§ 1 (0–2) 2 (1–2) 1 (0–3) p=0·193 data collection, data analysis, data interpretation, or
Median duration of aciclovir treatment, 21 (16–21) 21 (18–23) 21 (15–21) p=0·548 writing of the report. The corresponding author had full
days access to all the data in the study and had final
Steroids¶ 20 (39%) 5 (36%) 15 (41%) p=0·752 responsibility for the decision to submit for publication.
ICU admission 27 (53%) 9 (64%) 18 (49%) p=0·315
Antiepileptic drugs 40 (78%) 12 (86%) 28 (76%) p=0·422 Results
Median modified Rankin Scale Between Jan 1, 2014, and Oct 31, 2017, 54 patients with
At 6 months (n=48) 2 (1–3) 3 (3–4) 2 (1–3) p<0·001 herpes simplex encephalitis were recruited to Cohort A,
At 12 months (n=40) 2 (1–3) 3 (3–4) 2 (1–2) p<0·001 of whom 51 (n=50 HSV1 and n=1 HSV2) were included
in the analysis (n=3 died during the first 3 weeks of the
Data are median (IQR), n (%), n/N (%), or mean (SD). FLAIR=fluid-attenuated inversion recovery.
DWI=diffusion-weighted imaging. ICU=intensive care unit. *Likelihood ratio test. †Not assessable in 15 patients
disease; figure 1). The median time from neurological
(<3 years old, or severe decrease of the level of consciousness). ‡For lesion volume calculation, axial FLAIR sequences were symptom onset to inclusion in the study was 4 days
available in 33 patients (19 without autoimmune encephalitis and 14 with autoimmune encephalitis), and axial DWI (range 0–10); 29 (57%) patients were male. 48 (94%)
sequences in 46 patients (32 without autoimmune encephalitis and 14 with autoimmune encephalitis). §The number
patients were followed-up for a minimum of 6 months;
of days from onset of herpes simplex encephalitis symptoms to initiation of aciclovir. ¶17 patients were treated with
intravenous dexamethasone and three patients with intravenous methylprednisolone (with two also treated with of the other three patients, one died at week 9, one died at
intravenous immunoglobulins). week 10, and one had less than 6 months of follow-up.
40 (78%) were followed-up for 1 year; of the other eight
Table 1: Demographics and clinical features of patients in Cohort A
patients, one died at 9 months, one was lost to follow-up,
and six had less than 1 year of follow-up.
aged 12 years or younger, and 30 mg/kg per day for In Cohort A, 37 (73%) of the 51 patients included in
patients older than 12 years, divided every 8 h for the analysis had progressive neurological improvement
14–21 days) as soon as herpes simplex encephalitis was or stable deficits; one patient died at week 9, from
diagnosed. Concomitant use of steroids, intravenous aspiration pneumonia (an 11-year-old patient), one died
immunoglobulins, or both was at the physician’s at week 10, from malignant thymoma (a 30-year-old
discretion. patient), and one died at week 36, from lung
Written informed consent was obtained from all complications (an 84-year-old patient; figure 1). 14 (27%)
patients or their guardians. Studies were approved by the patients developed new-onset CNS symptoms or
Internal Review Board of Hospital Clinic, University of worsening of previous deficits consistent with probable
Barcelona. autoimmune encephalitis after herpes simplex

4 www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8

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encephalitis (table 1). Median time from herpes
simplex encephalitis until probable autoimmune
encephalitis was 32 days (IQR 22–43; range 7–61).
Whereas all younger children (≤4 years; n=6; median
age 9 months [IQR 3–12, range 2–15]) developed
symptoms associated with choreoathetosis, all older
children (>4 years) and adults (n=8, median age
66 years [IQR 40–78, range 13–81]) developed symptoms
without choreoathetosis in which behavioural and
psychiatric manifestations predominated (table 2).
Brain MRI scans at onset of herpes simplex
encephalitis, with fluid-attenuated inversion recovery
(FLAIR) and dif­fusion-weighted imaging (DWI), showed
no significant differences in lesion volume between
patients who developed autoimmune encephalitis and
those who did not (table 1; appendix). Among patients
who developed autoimmune encephalitis (n=14), MRI
scans at onset showed that nine (82%) of 11 patients had
contrast enhancement comparable with that found
during the viral encephalitis; similar findings were
observed in patients who did not develop autoimmune
encephalitis and had MRI at 1–3 months’ follow-up
(six [60%] of ten patients, p=0·269; figure 2). Patients
who developed auto­ immune encephalitis were more
likely to have necrosis with cystic lesions in MRI scans
obtained at follow-ups later than 4 months after herpes
simplex encephalitis, compared with patients who did
not develop autoimmune encephalitis (nine [100%] of

mRS 3 weeks Day of onset and main Maximum Antibody findings at Day immunotherapy was mRS at Outcome at 12 months’
after herpes symptoms of mRS during diagnosis of autoimmune started 12 months follow-up after herpes
simplex autoimmune autoimmune encephalitis after herpes simplex encephalitis
encephalitis* encephalitis after herpes encephalitis simplex
simplex encephalitis encephalitis
Serum (titre) CSF (titre)
Patient #1 male, 2 Day 7: choreoathetosis 3 NMDAR NMDAR Not treated with 4 Developmental delay,
2 months old (1/200) (1/40) immunotherapy refractory epilepsy,
infantile spasms, cortical
blindness, microcephaly
Patient #2 male, 2 Day 24: choreoathetosis, 5 NMDAR NMDAR (titre Day 26: intravenous 3 Developmental delay,
3 months old refractory seizures, LCE, (1/1600) not available) methylprednisolone, plasma right-sided hemiparesis,
hypotonia, dysphagia exchange, rituximab microcephaly
Patient #3 female, 2 Day 25: choreoathetosis, 5 NMDAR NMDAR Day 25: intravenous 4 Developmental delay,
7 months old refractory seizures, status (1/800) (1/20) methylprednisolone, spastic tetraparesis,
epilepticus, infantile intravenous anarthria, and controlled
spasms, LCE, hypotonia, immunoglobulins; day 60: epilepsy
dysphagia rituximab, cyclophosphamide
Patient #4 male, 2 Day 19: refractory 5 NMDAR NMDAR Day 20: intravenous 5 Developmental delay,
11 months old seizures, infantile spasms, (1/200) (1/160) methylprednisolone, spastic tetraparesis,
LCE, hypotonia, intravenous refractory epilepsy
dysphagia, immunoglobulins, rituximab,
choreoathetosis cyclophosphamide; day 70:
plasma exchange
Patient #5 male, 2 Day 39: choreoathetosis, 5 NMDAR NMDAR Day 32: intravenous 3 Delay in language skills
12 months old loss of language skills, (1/800) (1/160) methylprednisolone,
LCE, hypotonia, dysphagia intravenous
immunoglobulins, rituximab
Patient #6 male, 2 Day 27: refractory status 5 NMDAR† NMDAR† Day 28: intravenous 4 Developmental delay,
15 months old epilepticus, hypotonia, (1/200) (1/80) methylprednisolone; day 44: refractory epilepsy
LCE, dysphagia, plasma exchange, rituximab
choreoathetosis
Patient #7 male, 4 Day 43: aggressive 5 NMDAR NMDAR Day 190: intravenous 3 Residual motor and
13 years old behaviour, psychosis, (1/800) (1/160) methylprednisolone cognitive deficits
headache, high blood
pressure
Patient #8 female, 2 Day 45: insomnia, anxiety, 3 NMDAR NMDAR Day 60: inatravenous 0 Complete recovery
34 years old irritability, fear, sleep (1/200) (1/80) methylprednisolone
fragmentation and
nightmares
Patient #9 male, 3 Day 44: headache, 4 Negative NMDAR Day 140: intravenous 3 Residual aphasia
45 years old confusion, agitation, (1/20) methylprednisolone
psychosis, insomnia,
delusional thoughts
Patient #10 4 Day 39: emotional lability, 4 Negative Unknown Day 160: intravenous 3 Anterograde amnesia
female, 56 years suicidal ideation, antigen (1/40) methylprednisolone
old psychosis, confusion
(Table 2 continues on next page)

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mRS 3 weeks Day of onset and main Maximum Antibody findings at Day immunotherapy was mRS at Outcome at 12 months’
after herpes symptoms of mRS during diagnosis of autoimmune started 12 months follow-up after herpes
simplex autoimmune autoimmune encephalitis after herpes simplex encephalitis
encephalitis* encephalitis after herpes encephalitis simplex
simplex encephalitis encephalitis
Serum (titre) CSF (titre)
(Continued from previous page)
Patient #11 4 Day 37: confusion, 4 Negative Unknown Day 180: intravenous 4 Anterograde amnesia
female, 75 years aggressive behaviour, antigen (1/20) methylprednisolone,
old insomnia intravenous
immunoglobulins, rituximab,
cyclophosphamide
Patient #12 male, 3 Day 22: progressive 4 Unknown Unknown Day 159: intravenous 4 Anterograde amnesia
77 years old irritability, paranoid antigen antigen (1/20) methylprednisolone and irritability
thoughts, psychosis (1/800)
Patient #13 3 Day 17: fever, seizures, 5 Negative Unknown Day 21: steroids, intravenous 3 Anterograde amnesia
female, 78 years irritability, decreased level antigen (1/10) immunoglobulins, rituximab,
old of consciousness, cyclophosphamide
abnormal behaviour,
confusion, apathy
Patient #14 4 Day 63: progressive 4 Negative Unknown Day 90: intravenous steroids, 3 Anterograde amnesia
female, 80 years depression, apathy antigen intravenous
old (1/160) immunoglobulins
mRS=modified Rankin Scale. NMDAR=NMDA receptor. LCE=loss of contact with environment. *Except for patients 1, 4, and 13, who developed autoimmune encephalitis before the 3-week follow-up (figure
3A). †Coexisting GABAA receptor antibodies.

Table 2: Clinical features of patients with autoimmune encephalitis after herpes simplex encephalitis in Cohort A

nine patients vs seven [50%] of 14 patients; p=0·019;
figure 2). There were no differences in progression of
local white-matter or grey-matter abnormalities or local
atrophy between patients who developed autoimmune
encepha­litis and those who did not (appendix).
CSF studies at onset of herpes simplex encephalitis
and at 3 weeks’ follow-up showed no significant
differences in white blood cell count or total protein
concentration between patients who subsequently dev­
eloped autoimmune encephalitis and those who did not
(table 1; appendix). At the onset of autoimmune
encephalitis, the PCR of CSF for HSV1 and HSV2 was
negative in all patients, and all patients had mild
pleocytosis (median white blood cell count 17 per mm³
[IQR 7–54]) and increased protein concentration (median
61 mg/dL [IQR 39–88]).
At onset of herpes simplex encephalitis, none of the
51 patients included in the analysis of Cohort A had
antibodies against neuronal surface antigens. During
follow-up, all 14 (100%) patients who developed symptoms
consistent with autoimmune encephalitis tested positive
for IgG antibodies at or before the time of symptom
onset, including nine (64%) patients with NMDAR
antibodies (n=1 with co-existing GABAA receptor
antibodies), and five (36%) with antibodies against
unknown antigens (figures 3A, 4). Nine (64%) of these
14 patients were already antibody positive at the 3-week
follow-up (six were antibody positive preceding onset of
symptoms of autoimmune encephalitis); an example of
progressive NMDAR antibody development is shown in
the appendix. By contrast, among the 37 patients who did
not develop autoimmune encephalitis, 11 (30%) tested
positive for IgG antibodies during follow-up (p<0·001),
including three (27%) with NMDAR antibodies and
eight (73%) with antibodies against unknown antigens
(figure 3B). Compared with patients with autoimmune
encephalitis, only five (14%) of 37 patients tested positive
for neuronal surface antibodies at the 3-week follow-up
(p=0·0010). At 1-year follow-up, seven (50%) of 14 patients
with autoimmune encephalitis and one (4%) of 26 patients
without autoimmune encephalitis had antibodies
detectable in serum (p=0·0010; figure 3). The outcome of
patients with autoimmune encephalitis who had
persistent antibodies at 1-year follow-up was worse than
that of patients who became antibody negative (median
mRS 4 [IQR 3–5] vs 3 [3–3]; p=0·030).
The longest interval between herpes simplex
encephalitis and autoimmune encephalitis was 61 days,
and the sensitivity, specificity, positive predictive value,
and negative predictive value for the detection of
neuronal surface antibodies within 2 months after
herpes simplex encephalitis are shown in the appendix.
In paired serum and CSF testing, neuronal surface
antibodies were always present in CSF (19 [100%] of
19 patients) and less frequently in serum (11 [58%] of
19 patients; figure 3). In six patients who did not develop
autoimmune encephalitis, the antibodies were detected
during the clinical follow-up when only serum was
tested, according to the study design.
In the exploratory multivariate logistic regression
analysis, the presence of autoantibodies at the 3-week
follow-up was identified as a risk factor for autoimmune
encephalitis (OR 11·5, 95% CI 2·7–48·8; p<0·001;
appendix). Adjustment by patient’s age and other possible

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FLAIR T1 with contrast

HSE 1–3 months 6–9 months HSE 1–3 months 6–9 months

Case 1
(patient 4)

Case 2
(patient 10)

Case 3

Case 4
(patient 24)

Figure 2: MRI in patients who developed autoimmune encephalitis after herpes simplex encephalitis compared with those who did not develop autoimmune
encephalitis
Each row corresponds to a different patient and includes MRI scans obtained at diagnosis of herpes simplex encephalitis, at 1–3 month follow-up, and at 6–9 month
follow-up. The first three columns of images correspond to FLAIR sequences, and the last three columns to T1 sequences, all with contrast (except for the 6–9 month
T1 follow-up for patient 4). Case 1 (patient 4) was an 11-month-old boy who developed autoimmune encephalitis with NMDAR antibodies after herpes simplex
encephalitis. Case 2 (patient #10) was a 56 year-old woman who developed autoimmune encephalitis with antibodies against unknown neuronal surface antigens
after herpes simplex encephalitis. Case 3 (no patient number) was a 49 year-old woman who developed herpes simplex encephalitis without autoimmune
encephalitis or neuronal antibodies (she had history of lung adenocarcinoma, brain metastasis, and cranial radiotherapy). Case 4 (patient #24) was a 66 year-old
woman who developed NMDAR and GAD65 antibodies but did not have symptoms of autoimmune encephalitis. These patients were chosen because there was
good MRI follow-up and they were representative of the indicated subgroups. In all patients, MRI scans obtained at the 1–3 month follow-up show areas of FLAIR
hyperintensity (larger or similar to those obtained at diagnosis of herpes simplex encephalitis); however, MRIs of patients who developed autoimmune encephalitis
(first and second rows) show more extensive areas of post-necrotic cystic abnormalities than those who did not develop autoimmune encephalitis (third and fourth
rows). Note that all patients, except patient 24, have areas of contrast enhancement at 1–3 month follow-up. FLAIR=fluid-attenuated inversion recovery. HSE=herpes
simplex encephalitis. NMDAR=NMDA receptor.

effect modifiers was not associated with a clinically
meaningful change in OR (appendix).
At 1-year follow-up, patients who developed auto­immune
encephalitis had more neurological deficits (median
mRS 3 [IQR 3–4] vs 2 [1–2]; p<0·001; table 1) and were
more frequently treated with anti-epileptic drugs than
were those who did not develop autoimmune encephalitis
(ten [71%] of 14 patients vs nine [35%] of 26; p=0·046).
Between Oct 7, 2011, and Oct 31, 2017, 48 patients
were included in Cohort B (median age 8·8 years
[IQR 1·1–44·2]; 26 male patients). These patients
developed new-onset or worsening neurological
symptoms not caused by herpes simplex virus
reactivation after completing treatment with aciclovir
(figure 1). Of these 48 patients, 44 (92%) had neuronal
surface antibodies; 34 (77%) of 44 had antibodies
against NMDAR and the other ten (23%) had antibodies
against unknown antigens (appendix). Antibodies were
more frequently detected in CSF (44 [100%] of
44 patients; median titres 1/40 [IQR 1/10 to 1/160]) than
in serum (25 [76%] of 33 patients, median titres 1/800
[1/400 to 1/3200]; appendix).

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A
Patient Sex Age Sample HSE Day 21 Day 60 Day 180 Day 365 Antigen Serum titres
Highest* Day 365
1 Male 2 months CSF – + NMDAR 1/3200 1/800
Day 7
Serum – + + + +

2 Male 3 months CSF – + + NMDAR 1/1600 1/400

Day 24
Serum – – + + + +

3 Female 7 months CSF – + NMDAR 1/12 800 1/800

Day 25
Serum – + + + +

4 Male 11 months CSF – + NMDAR 1/3200 1/1200

Day 19
Serum – + + + +

5 Male 12 months CSF – + + NMDAR† 1/3200 Negative

Day 39
Serum – + + + + –

6 Male 15 months CSF – + + NMDAR 1/3200 1/200

Day 27
Serum – + + + + +

7 Male 13 years CSF – – + NMDAR 1/3200 1/400

Day 43
Serum – – + + + +

8 Female 34 years CSF – – + NMDAR 1/200 Negative

Day 45
Serum – – + – – –

9 Male 45 years CSF – + + NMDAR (Only positive in CSF)

Day 44
Serum – – – – – –

10 Female 56 years CSF – – + Unknown (Only positive in CSF)

Day 39
Serum – – – – – –

11 Female 75 years CSF – – + Unknown (Only positive in CSF)

Day 37
Serum – – – – – –

12 Male 77 years CSF – + + Unknown 1/1600 1/800

Day 22
Serum – + + + + +

13 Female 78 years CSF – Day 17 + Unknown (Only positive in CSF)

Serum – – – – –

14 Female 80 years CSF – – Day 63 + Unknown (Only positive in CSF)

Serum – – – – – –

mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 Day of onset of autoimmune encephalitis

Figure 3 continues on next page

The median time from herpes simplex encephalitis
until symptoms of probable autoimmune encephalitis in
Cohort B was 31 days (IQR 25–49, range 11–306). Similar
to patients from Cohort A, patients who were aged 4 years
or younger (n=21, median age 10·6 months [IQR 7–20,
range 4·5–48]) developed symptoms associated with
choreoathetosis, whereas those older than 4 years (n=23,
median age 34 years [16–56, range 6–69]) developed
symptoms in which behavioural and psychiatric
manifestations predominated (appendix). Of the total
48 patients in Cohort B, the remaining four (8%) patients
without neuronal surface antibodies had main clinical
features of epileptic seizures (n=3) and behavioural
change (n=1; appendix).
Considering all 58 patients from both cohorts who
developed antibody-associated autoimmune encephalitis
after herpes simplex encephalitis, we identified symptoms
that were age-dependent: patients aged 4 years or younger
(n=27) developed prominent choreoathetosis, behavioural
change, decreased level of consciousness, truncal
hypotonia, dysphagia, and frequent refractory seizures
(table 3). Six (22%) of these 27 patients developed infantile
spasms during the acute phase of autoimmune en­
cephalitis, and another two at later stages (6–12 months’
follow-up). By contrast, patients older than 4 years (n=31)
developed prominent change of behaviour and psychiatric
symptoms, had less frequent seizures or decreased level of
consciousness, and no choreoatherosis. 18 (58%) of these
31 patients presented with psychosis (in younger children,
psychosis was not assessable). Compared with patients
older than 4 years, patients aged 4 years or younger (all
with choreoathetosis) were more likely to have a shorter
interval between herpes simplex encephalitis and
autoimmune encephalitis, seizures, decreased level of
consciousness, NMDAR antibodies, and worse outcome at
1 year, including a higher mRS score and more frequent
seizures than patients older than 4 years (table 3).
Compared with patients with antibodies other than
NMDAR (n=15), patients with NMDAR antibodies (n=43)
were more likely to be younger and develop psychosis,

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B
Patient Sex Age Sample HSE Day 21 Day 60 Day 180 Day 365 Antigen Serum titres
Highest* Day 365
15 Female 12 CSF – + NA Unknown 1/12 800 NA
months Serum – + + +

16 Male 26 CSF – + Unknown (Only positive in CSF)

months Serum – – – – –

17 Female 22 years CSF – + Unknown (Only positive in CSF)

Serum – – – – –

18 Female 49 years CSF – – Unknown 1/1600 1/1200

Serum – – + + +

19 Male 51 years CSF – + Unknown 1/400 Negative

Serum – + – – –

20 Female 55 years CSF – – Unknown 1/400 Negative

Serum – – + + –

21 Male 59 years CSF – – Unknown 1/200 Negative

Serum – – + – –

22 Male 61 years CSF – – NMDAR 1/800 Negative

Serum – – + + –

23 Female 63 years CSF – + NMDAR (Only positive in CSF)

Serum – – – – –

24 Female 66 years CSF – – NMDAR‡ 1/200 Negative

Serum – – – + –

25 Male 71 years CSF – – Unknown 1/400 Negative

Serum – – – + –

mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 Day of onset of autoimmune encephalitis

Figure 3: Timing of antibody detection, development of autoimmune encephalitis, and follow-up of serum testing and neurological status
(A) Patients from Cohort A who developed neuronal surface antibodies in association with autoimmune encephalitis. None of the patients had neuronal surface antibodies at the time of onset of
herpes simplex encephalitis, but all were antibody-positive at or before onset of symptoms of autoimmune encephalitis. In all patients, the presence (+) or absence (–) of neuronal cell-surface
antibodies in serum was followed for 1 year. The neurological status was measured with the mRS and is colour-coded. (B) Patients from Cohort A who developed neuronal surface antibodies without
autoimmune encephalitis. These patients became antibody-negative sooner (as measured in serum) than did patients with autoimmune encephalitis. HSE=herpes simplex encephalitis.
NMDAR=NMDA receptor. NA=not available. mRS=modified Rankin Scale. *In all patients, the highest serum titres were identified within the first 2 months of follow-up. †NMDAR antibodies with
co-existing GABAA receptor antibodies. ‡NMDAR antibodies with co-existing GAD65 antibodies; at 1 year follow-up only GAD65 antibodies remained detectable (not shown).

choreoathetosis, decreased level of consciousness, and
dysautonomia (appendix). No differences in neurological
outcome (mRS) were noted between patients with
autoimmune encephalitis with NMDAR antibodies and
those with other neuronal surface antibodies (appendix).
Discussion
In the prospective Cohort A, 27% of patients with herpes
simplex encephalitis developed symptoms of auto­
immune encephalitis within 3 months of completing
treat­
ment with aciclovir; neurological symptoms,
response to immunotherapy, and long-term outcome
varied according to the patients’ age. Patients aged 4 years
or younger developed choreoathetosis, decreased level
of consciousness, and frequent seizures or infantile
spasms, whereas children aged more than 4 years and
adults predominantly developed a change of behaviour
and psychiatric symptoms sometimes accompanied by
seizures. Additionally, older children and adults were
more likely to respond to immunotherapy. There were
similar findings regarding age-related symptoms and
different outcomes in the retrospective Cohort B, in
which patients who developed unexplained neurological
symptoms after treatment of herpes simplex encephalitis
were investigated for antibodies against neuronal
surface proteins.
When Cohort A was examined for risk factors of
autoimmune encephalitis, the main feature identified
was the detection of neuronal antibodies at 3-week
follow-up. Considering that none of the patients tested
positive for these antibodies at onset of herpes simplex
encephalitis, this finding suggests the viral infection
triggered the immune response. We do not know
whether any of these immune responses occurred as a
result of viral-induced release of NMDAR and other
proteins, or by mechanisms of molecular mimicry, such
as similarity between NMDAR and herpes simplex virus
proteins. The high frequency of antibodies against
different neuronal antigens supports the first possibility
but does not rule out that molecular mimicry might also
be involved. One study23 showed that patients with
classic anti-NMDAR encephalitis (not herpes simplex

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A B

C D

E F

500 µm 10 µm

Figure 4: Antibodies against neuronal surface antigens

Sagittal sections of rat hippocampus immunolabelled with CSF from a patient with NMDA receptor antibodies (A), with CSF from a patient with antibodies against
unknown neuronal antigens (C), and with CSF from a patient without neuronal antibodies (E). We used the same patients’ samples to immunolabel primary cultures
of live rat hippocampal neurons (B, D, and F, respectively). In B, D and F, the nuclei of the neurons are shown with DAPI (nucleic acid stain).

encephalitis-related) were more likely to have herpes
simplex virus anti­ bodies than were an age-matched
control population, suggesting the possibility of
molecular mimicry between herpes simplex virus and
NMDAR.23 Although the role of human leukocyte
antigen in predisposing people to anti-NMDAR
encephalitis is still unclear,24,25 future studies should
determine whether there is a predisposition among
patients with herpes simplex encephalitis to develop
autoimmune encephalitis.
In Cohort A, clinical and immunological follow-up
showed that the development of autoantibodies
preceded the onset of autoimmune encephalitis, and
that not all antibody-positive patients developed neuro­
logical worsening. Moreover, at 1-year follow-up,
seven (50%) of 14 patients who developed autoimmune
encephalitis remained IgG antibody positive despite the
use of immunotherapy in 13 cases, whereas one (4%) of
26 patients who did not develop autoimmune
encephalitis and therefore did not receive immuno­
therapy remained antibody positive. These findings
indicate that herpes simplex encephalitis can initiate, in
some patients, a transient and subclinical synthesis of
neuronal antibodies that becomes undetectable several

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months after the infection. Only a longer follow-up of

Patients ≤4 years Patients >4 years Comparison
these patients will clarify if they have a propensity to (n=27) (n=31)
develop autoimmune encephalitis; in fact, four adult
Median age, range 11 months (7–17), 42 years (18–60), ··
patients from Cohort B (in whom antibody findings range 2–48 range 6–80
were not prospectively followed up) developed late Median interval between herpes simplex 26 days (24–32), 43 days (25–54), p=0·0073
symptoms of autoimmune encephalitis (306 days) or encephalitis and autoimmune encephalitis, range range 7–61 range 11–306
relapses at 60, 699, and 723 days after herpes simplex Main symptoms of autoimmune encephalitis
encephalitis (appendix). Change of behaviour* 26 (96%) 28 (90%) p=0·615
The symptoms associated with autoimmune Seizures 15 (56%)† 7 (23%)‡ p=0·015
encephalitis after herpes simplex encephalitis varied Choreoathetosis 27 (100%) 0 p<0·001
according to the patient’s age, and partially resembled Decreased level of consciousness§ 26 (96%) 7 (23%) p<0·001
the symptom onset of classical anti-NMDAR Dysautonomia 9 (33%) 6 (19%) p=0·247
encephalitis.19 Children with this disorder usually present Antibodies
with seizures, behavioural change, choreoathetosis, or NMDA receptor 24 (89%)¶ 19 (61%) p=0·033
decreased level of conscious­ness,9,26–28 whereas teenagers Unknown antigens 3 (11%) 12 (39%) p=0·030
and adults are more prone to present with behavioural, Immunotherapy
psychiatric, and cognitive changes, and (less frequently) No immunotherapy 2 (7%) 4 (13%) p=0·675
seizures.29–31 These age-related symptoms could explain First line 25 (93%)|| 27 (87%)** p=0·675
why the relapsing neuro­logical symptoms after herpes
Second line 15 (56%)†† 8 (26%)‡‡ p=0·030
simplex encephalitis have been more frequently
Seizures at 12 months’ follow-up 12/19 (63%) 3/23 (13%) p=0·001
described among children than adults. Indeed, new-
Taking anti-epileptic drugs at 12 months’ 19/19 (100%) 13/23 (57%) p=0·001
onset choreoathetosis and other movement disorders are follow-up
readily identified on clinical grounds, but changes of Median mRS at follow-up
behaviour, cognition, and memory can be attributed to 6 months 4 (4–5) 3 (2–3) p<0·001
residual deficits of herpes simplex encephalitis.8 The 12 months 4 (4–4) 2 (2–3) p<0·001
susceptibility of young children to develop post-infectious
Data are median (IQR), n (%), or n/N (%), unless otherwise stated. mRS=modified Rankin Scale. *Manifested as
movement disorders or seizures has been noted in other irritability and poor response to stimuli and environment in very young children (≤4 years); among children older than
disorders such as post-streptococcal chorea (also known 4 years, and adults, 18 patients developed full-blown psychosis. †Ten patients with status epilepticus (six with infantile
as Sydenham chorea) and fever-induced seizures, spasms). ‡Four patients with status epilepticus. §Including loss of contact with environment in children. ¶One patient
with co-existing GABAA receptor antibodies. ||Combined intravenous methylprednisolone and intravenous
suggesting an enhanced susceptibility of specific synaptic
immunoglobulins (n=13), combined intravenous methylprednisolone, intravenous immunoglobulins, and plasma
networks to inflammatory or autoimmune exchange (n=7), intravenous methylprednisolone alone (n=3), intravenous immunoglobulins alone (n=1), and plasma
mechanisms.32,33 A similar type of sus­ceptibility might exchange alone (n=1). **Combined intravenous methylprednisolone and intravenous immunoglobulins (n=11),
explain why 22% of younger but not older children with combined intravenous methylprednisolone, intravenous immunoglobulins, and plasma exchange (n=3), intravenous
methylprednisolone alone (n=12), and intravenous immunoglobulins and oral corticosteroids (n=1). ††All 15 patients
NMDAR antibodies after herpes simplex encephalitis were treated with rituximab and six patients also received cyclophosphamide. ‡‡All eight patients were treated with
developed early infantile spasms as part of autoimmune rituximab and four patients also received cyclophosphamide.
encephalitis.34 The timeframe of this complication is
Table 3: Symptoms of antibody-confirmed autoimmune encephalitis after herpes simplex encephalitis,
different from that of classical infantile spasms that in Cohorts A and B, stratified by age
typically develop several months after a precipitating
event, such as a brain infection or another type of brain
injury.35 Indeed, two other patients (patient #1 in A reason for this worse outcome might be related to the
Cohort A, patient #13 in Cohort B) with autoimmune presence of clinical or subclinical deficits caused by the
encephalitis after herpes simplex encephalitis and two viral encephalitis.2 Additional mechanisms, such as
patients (in Cohort A) without autoimmune encephalitis complement-mediated or T-cell-mediated cytotoxicity,
or antibodies developed classical infantile spasms which do not seem to have major pathogenic roles
6–12 months after herpes simplex encephalitis (data not in classical autoimmune encephalitis,37,38 might be more
shown). relevant in cases of autoimmune encephalitis after
In both cohorts, the prognosis of young children with herpes simplex encephalitis, and deserve future study.
autoimmune encephalitis after herpes simplex en­ For example, in a previous study,29 we found that only
cephalitis was substantially worse than that reported in 180 (33%) of 540 patients with classic anti-NMDAR
patients with classical anti-NMDAR encephalitis,27–29 encephalitis had brain MRI abnormalities, and these
and that reported in small case series of autoimmune rarely enhanced with contrast. By comparison,
encephalitis after herpes simplex encephalitis.7–11 nine (82%) of 11 patients with autoimmune encephalitis
Although older children and adults with autoimmune after herpes simplex encephalitis in this study had areas
encephalitis after herpes simplex encephalitis had better of contrast enhancement (similar to those found during
outcomes than the younger children, their outcomes the viral encephalitis), suggesting blood–brain barrier
were notably worse than those described in patients of disruption with the potential for entry of complement
the same age with classical anti-NMDAR encephalitis.29,36 and other pro-inflammatory molecules.39 Whether a

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systematic use of anti-inflammatory drugs or immuno­
therapy during the viral phase of the disease could
prevent the development of autoimmune encephalitis
warrants future study. There was no significant
difference in the use of steroids between patients who
developed autoimmune encephalitis and those who did
not, but the number of cases is small and not all patients
were treated similarly.
This study has several limitations. The number of
individuals in the prospective Cohort A is relatively
small. Although all patients in Cohort A had paired
serum and CSF antibody testing at two different
timepoints (diagnosis of herpes simplex encephalitis,
and 3 weeks later), and additionally if they developed
autoimmune encephalitis, only serum testing was done
in later follow-ups. Because of this, it is possible that we
underestimated the number of patients who, without
neurological worsening, could have developed CSF
antibodies at a later time. The identity of some of the
cell-surface antigens is unknown. The serum and CSF
of these patients were extensively studied for reactivity
with known neuronal cell-surface antigens using cell-
based assays, rat brain immuno­staining, and cultured
live neurons, with positive results only seen with brain
tissue and live neuronal staining. Although antibodies
for the D(2) dopamine receptor were previously reported
in some patients with autoimmune encephalitis after
herpes simplex encephalitis,11 we did not identify these
antibodies in these cohorts. Further work is needed to
identify these unknown targets. Finally, in Cohort B, the
retrospective collection of information through a
questionnaire sent to clinicians can be perceived as a
limitation, but only the information related to herpes
simplex encephalitis was obtained retrospectively.
This study raises awareness for autoimmune encephalitis
triggered by herpes simplex encephalitis, and reveals a
predictable timeframe (approximately 2 months) in which
patients with herpes simplex encephalitis might develop
autoimmune encephalitis associated with immune
responses against NMDAR and other neuronal surface
proteins. Autoimmune encephalitis should be strongly
considered in patients who, within this timeframe, develop
new neurological or psychiatric symptoms, characterised
in younger children by choreoathetosis, and in older
children and adults by cognitive and behavioural
impairment or psychosis. In this context, detection of
NMDAR or other neuronal surface antibodies is
confirmatory of autoimmune encephalitis. Recognition of
this complication is important because a substantial
number of patients, mainly older children and adults,
respond to immunotherapy. The challenges are now to
determine the mechanisms involved, whether anti-
inflammatory or immunotherapy prophylaxis during
herpes simplex encephalitis prevents autoimmune
encephalitis, if there are predisposing genetic factors, and
whether earlier diagnosis and treatment could improve
outcome.
12 www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8
Contributors
TA and JD obtained funding for the study. TA, FG, and JD designed
the study. TA did the literature search. TA, AV, MEE, LAb, GM, LMG,
ICC, CM, MT, LB, GS, HA, EuM-H, MJ, MAM, LAl, AS, and MRR
collected the data. TA, MS, FG, and JD interpreted the data. TA, SM,
MC-C, ElM-H, SL, and JM did the radiological analysis. TA did the
statistical analysis. TA and MS developed the figures. TA and
JD wrote the first draft and all authors critically approved the final
paper.
Spanish Herpes Simplex Encephalitis Study Group
Sergio Aguilera-Albesa, Alfonso Amado-Puentes,
Antonio Arjona-Padillo, Luisa Arrabal, Izascun Arratibel,
Gemma Aznar-Laín, Paula Bellas-Lamas, Teresa Bermejo,
Sabas Boyero-Durán, Ana Camacho, Andrea Campo, Dulce Campos,
Verónica Cantarín-Extremera, Cristóbal Carnero, David Conejo-Moreno,
Marta Dapena, David Dacruz-Álvarez, Verónica Delgadillo-Chilavert,
Angela Deyà, Jordi Estela-Herrero, Anna Felipe, Elisa Fernández-Cooke,
Joaquín Fernández-Ramos, Claudia Fortuny, Juan C García-Monco,
Teresa Gili, Verónica González-Álvarez, Robert Guerri, Sara Guillén,
Antonio Hedrera-Fernández, María López, Eduardo López-Laso,
María Lorenzo-Ruiz, Marcos Madruga, Ignacio Málaga-Diéguez,
Itxaso Martí-Carrera, Xavier Martínez-Lacasa, Lucía Martín-Viota,
Leticia Martín Gil, María-Jesús Martínez-González, Antia Moreira,
María C Miranda-Herrero, Lorena Monge, Beatriz Muñoz-Cabello,
Juan Navarro-Morón, Olaf Neth, Antoni Noguera-Julian,
Noemí Nuñez-Enamorado, Virginia Pomar, Juan C Portillo-Cuenca,
María Poyato, Luis Prieto, Luis Querol, Eloy Rodríguez-Rodríguez,
Silvana Sarria-Estrada, Concepción Sierra, Pere Soler-Palacín,
Víctor Soto-Insuga, Laura Toledo-Bravo, Miguel Tomás,
Carmen Torres-Torres, Eulàlia Turón, Ana Zabalza.
Declaration of interests
JD holds patents for the use of Ma2, NMDA receptors (NMDAR),
GABAB receptors, GABAA receptors, DPPX, and IgLON5 as autoantibody
tests. FG holds a patent for the use of IgLON5 as an autoantibody test.
MRR holds patents for the use of Ma2 and NMDAR as autoantibody
tests. JD, FG, and MRR receive royalties related to autoantibody tests
from Athena Diagnostics and Euroimmun Inc. All other authors declare
no competing interests.
Acknowledgments
The authors thank Maria Rodes, Mercè Alba, Eva Caballero, and
Esther Aguilar for excellent administrative and technical support,
Jesus Planagumà for helping to develop figure 4, Georgina Casanova for
assisting in the statistical analyses, and patients and families for
participating in this study. This study was supported in part by Mutua
Madrileña Foundation Award AP162572016 (TA); Fondation de
l’Université de Lausanne et Centre Hospitalier Universitaire Vaudois
(MS); Instituto Carlos III/CM16/00136 (HA); and Instituto Carlos
III/FEDER 17/00234, CIBERER 15/00010, NIH RO1NS077851,
Generalitat de Catalunya AGAUR SGR93, and Fundació CELLEX (JD).
References
1 Hjalmarsson A, Blomqvist P, Skoldenberg B. Herpes simplex
encephalitis in Sweden, 1990–2001: incidence, morbidity, and
mortality. Clin Infect Dis 2007; 45: 875–80.
2 Gnann JW Jr, Whitley RJ. Herpes simplex encephalitis: an update.
Curr Infect Dis Rep 2017; 19: 13.
3 Barthez-Carpentier MA, Rozenberg F, Dussaix E, et al. Relapse of
herpes simplex encephalitis. J Child Neurol 1995; 10: 363–68.
4 Ito Y, Kimura H, Yabuta Y, et al. Exacerbation of herpes simplex
encephalitis after successful treatment with acyclovir. Clin Infect Dis
2000; 30: 185–87.
5 De Tiege X, Rozenberg F, Des Portes V, et al. Herpes simplex
encephalitis relapses in children: differentiation of two neurologic
entities. Neurology 2003; 61: 241–43.
6 Skoldenberg B, Aurelius E, Hjalmarsson A, et al. Incidence and
pathogenesis of clinical relapse after herpes simplex encephalitis in
adults. J Neurol 2006; 253: 163–70.
7 Armangue T, Leypoldt F, Malaga I, et al. Herpes simplex virus
encephalitis is a trigger of brain autoimmunity. Ann Neurol 2014;
75: 317–23.

8 Armangue T, Moris G, Cantarin-Extremera V, et al.
Autoimmune post-herpes simplex encephalitis of adults and
teenagers. Neurology 2015; 85: 1736–43.
9 Armangue T, Titulaer MJ, Malaga I, et al. Pediatric
anti-N-methyl-D-aspartate receptor encephalitis-clinical analysis and
novel findings in a series of 20 patients. J Pediatr 2013; 162: 850–56.
10 Hacohen Y, Deiva K, Pettingill P, et al. N-methyl-D-aspartate
receptor antibodies in post-herpes simplex virus encephalitis
neurological relapse. Mov Disord 2014; 29: 90–96.
11 Mohammad SS, Sinclair K, Pillai S, et al. Herpes simplex
encephalitis relapse with chorea is associated with autoantibodies to
N-methyl-D-aspartate receptor or dopamine-2 receptor. Mov Disord
2014; 29: 117–22.
12 Pruss H, Finke C, Holtje M, et al. N-methyl-D-aspartate receptor
antibodies in herpes simplex encephalitis. Ann Neurol 2012;
72: 902–11.
13 Alexopoulos H, Akrivou S, Mastroyanni S, et al. Postherpes simplex
encephalitis: a case series of viral-triggered autoimmunity, synaptic
autoantibodies and response to therapy. Ther Adv Neurol Disord
2018; 11: 1756286418768778.
14 Westman G, Sohrabian A, Aurelius E, et al. Clinical significance of
IgM and IgA class anti-NMDAR antibodies in herpes simplex
encephalitis. J Clin Virol 2018; 103: 75–80.
15 Hargrave DR, Webb DW. Movement disorders in association with
herpes simplex virus encephalitis in children: a review.
Dev Med Child Neurol 1998; 40: 640–42.
16 Nosadini M, Mohammad SS, Corazza F, et al. Herpes simplex
virus-induced anti-N-methyl-d-aspartate receptor encephalitis:
a systematic literature review with analysis of 43 cases.
Dev Med Child Neurol 2017; 59: 796–805.
17 van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J.
Interobserver agreement for the assessment of handicap in stroke
patients. Stroke 1988; 19: 604–07.
18 Bigi S, Fischer U, Wehrli E, et al. Acute ischemic stroke in children
versus young adults. Ann Neurol 2011; 70: 245–54.
19 Dalmau J, Gleichman AJ, Hughes EG, et al. Anti-NMDA-receptor
encephalitis: case series and analysis of the effects of antibodies.
Lancet Neurol 2008; 7: 1091–98.
20 Hara M, Martinez-Hernandez E, Arino H, et al. Clinical and
pathogenic significance of IgG, IgA, and IgM antibodies against the
NMDA rece ptor. Neurology 2018; 90: e1386–94.
21 Afifi A, Clark V, May S. Practical multivariate analysis. London:
Chapman & Hall/CRC Texts in Statistical Science, 2012.
22 Hosmer D, Lemeshow S, Sturdivant R. Applied logistic regression.
New York: Wiley Series in Probability and Statistics, 2013.
23 Salovin A, Glanzman J, Roslin K, Armangue T, Lynch DR,
Panzer JA. Anti-NMDA receptor encephalitis and nonencephalitic
HSV-1 infection. Neurol Neuroimmunol Neuroinflamm 2018; 5: e458.
24 Kim TJ, Lee ST, Moon J, et al. Anti-LGI1 encephalitis is associated
with unique HLA subtypes. Ann Neurol 2017; 81: 183–92.
www.thelancet.com/neurology Published online July 23, 2018 http://dx.doi.org/10.1016/S1474-4422(18)30244-8 13
Articles
25 Mueller SH, Farber A, Pruss H, et al. Genetic predisposition in
anti-LGI1 and anti-NMDA receptor encephalitis. Ann Neurol 2018;
83: 863–69.
26 Florance NR, Davis RL, Lam C, et al. Anti-N-methyl-D-aspartate
receptor (NMDAR) encephalitis in children and adolescents.
Ann Neurol 2009; 66: 11–18.
27 Favier M, Joubert B, Picard G, et al. Initial clinical presentation of
young children with N-methyl-d-aspartate receptor encephalitis.
Eur J Paediatr Neurol 2017; 22: 404–11.
28 Ho AC, Chan SH, Chan E, et al. Anti-N-methyl-d-aspartate receptor
encephalitis in children: Incidence and experience in Hong Kong.
Brain Dev 2018; 40: 473–79.
29 Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and
prognostic factors for long-term outcome in patients with
anti-NMDA receptor encephalitis: an observational cohort study.
Lancet Neurol 2013; 12: 157–65.
30 Viaccoz A, Desestret V, Ducray F, et al. Clinical specificities of adult
male patients with NMDA receptor antibodies encephalitis.
Neurology 2014; 82: 556–63.
31 Irani SR, Bera K, Waters P, et al. N-methyl-D-aspartate antibody
encephalitis: temporal progression of clinical and paraclinical
observations in a predominantly non-paraneoplastic disorder of
both sexes. Brain 2010; 133: 1655–67.
32 Bale JF Jr, Du Pasquier R. Relapse in herpes simplex virus
encephalitis: it’s not just about the virus. Neurology 2015;
85: 1730–31.
33 Dube CM, Brewster AL, Baram TZ. Febrile seizures:
mechanisms and relationship to epilepsy. Brain Dev 2009;
31: 366–71.
34 Paolicchi JM. The timing of pediatric epilepsy syndromes: what are
the developmental triggers? Ann N Y Acad Sci 2013; 1304: 45–51.
35 Aznar Lain G, Dellatolas G, Eisermann M, et al. Children often
present with infantile spasms after herpetic encephalitis. Epilepsia
2013; 54: 1571–76.
36 Titulaer MJ, McCracken L, Gabilondo I, et al. Late-onset anti-NMDA
receptor encephalitis. Neurology 2013; 81: 1058–63.
37 Dalmau J, Tuzun E, Wu HY, et al. Paraneoplastic
anti-N-methyl-D-aspartate receptor encephalitis associated with
ovarian teratoma. Ann Neurol 2007; 61: 25–36.
38 Martinez-Hernandez E, Horvath J, Shiloh-Malawsky Y, Sangha N,
Martinez-Lage M, Dalmau J. Analysis of complement and plasma
cells in the brain of patients with anti-NMDAR encephalitis.
Neurology 2011; 77: 589–93.
39 Al-Obaidi MMJ, Bahadoran A, Wang SM, Manikam R, Raju CS,
Sekaran SD. Disruption of the blood brain barrier is vital property
of neurotropic viral infection of the central nervous system.
Acta Virol 2018; 62: 16–27.