Refractory anti-NMDAR encephalitis successfully treated with bortezomib and associated movements disorders controlled with tramadol: a case report with literature review.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a potentially fatal autoimmune disease, characterized by autoantibody-mediated neurotransmission impairment in multiple brain locations. The course of this condition often comprises altered mental status, autonomic dysfunctions, refractory seizures and hyperkinetic movement disorders. Available disease-modifying therapies include corticosteroids, i.v. immunoglobulins, plasma exchange, rituximab and cyclophosphamide. In a subgroup of patients not responding to B-cell depletion, bortezomib, a proteasome inhibitor, has shown promising evidence of efficacy. The time course of recovery from acute phase may be very slow (weeks/months), and only few data are available in literature about the concurrent management of encephalitis-associated movement disorders. We report a case of severe anti-NMDAR encephalitis in a 29-year-old woman, not responsive to first- and second-line treatments, with persistent involuntary motor manifestations. Starting three months after symptom onset, four cycles of bortezomib have been administered; subsequently we observed a progressive improvement of neurological status. Meanwhile, motor manifestations were controlled after the administration of tramadol, a non-competitive NMDA receptor antagonist.

The Brachiocephalic Vein as a Safe and Viable Alternative to Internal Jugular Vein for Central Venous Cannulation.

BACKGROUND: Although many studies have compared success and complication rates for central line insertion sites with and without ultrasound, few have examined the use of the brachiocephalic vein for central venous access. The aim of this study was to describe the brachiocephalic vein as an alternative site for elective ultrasound vascular cannulation in adults, and to compare it with the more commonly used internal jugular vein site in terms of procedural difficulties, first pass failure rate, overall failure rate, and safety. METHODS: In this single-center, retrospective cohort study, clinical data from consecutive adult patients undergoing elective ultrasound-guided central venous catheterization of upper body were retrieved from the department database. All of these central venous catheters were requested by department team, none was positioned for surgery. Seven hundred nine patients underwent central venous catheterization via the internal jugular approach and 285 patients via the brachiocephalic route. Patients catheterized via the brachiocephalic vein approach were then compared with those catheterized via the internal jugular vein in terms of ease of catheterization, success rate, and complications. Differences between approaches were assessed by univariate analyses and multivariable analysis. RESULTS: Overall, 994 patients underwent central venous catheterization. A total of 87% had a successful catheter implantation at the first attempt, 6.7% of insertions were difficult, 5.7% were complicated, and 3.4% failed. Procedural difficulty was more frequent with the internal jugular than with the brachiocephalic approach (odds ratio, 0.38; 95% confidence interval, 0.19-0.76; P = .007) after correction for potential confounders. Differences between groups in complication rate (6.3% vs 4.1%) or failure rate (3.4% vs 3.5%) were not significant. CONCLUSIONS: Brachiocephalic cannulation is a reasonable alternative to ultrasound-guided internal jugular vein catheterization.