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Anti-LGI1 Encephalitis — SCE Neurology MCQ

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HardCNS InfectionsAnti-LGI1 EncephalitisSCE Neurology

A 68-year-old woman with anti-LGI1 encephalitis has persistent daily faciobrachial dystonic seizures and worsening memory 3 weeks after high-dose intravenous methylprednisolone followed by intravenous immunoglobulin. Infection and an occult tumour have been excluded. Which single agent is the preferred next escalation for this likely antibody-mediated disease?

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Correct answer: E — Rituximab as second-line immunotherapy

Persistent clinically important disease after an adequate first-line course warrants second-line immunotherapy rather than relying on a slow maintenance agent or antiseizure treatment alone. Rituximab is generally preferred for a likely antibody-mediated syndrome because it targets B cells and is less toxic than cyclophosphamide. Cyclophosphamide remains an alternative, particularly when a cell-mediated or paraneoplastic process is suspected. Azathioprine and mycophenolate are mainly steroid-sparing maintenance therapies and have a slower onset. Continuing corticosteroids alone despite deterioration would delay effective escalation.

Reference: Autoimmune encephalitis: proposed best practice recommendations for diagnosis and acute management: https://pmc.ncbi.nlm.nih.gov/articles/PMC8223680/