Refractory brainstem encephalitis mimicking progressive cerebral infarction: infliximab and methotrexate as a salvage immunotherapy

Abstract

Background Brainstem encephalitis is a rare, severe, and potentially life-threatening inflammation of the central nervous system, exhibiting various treatment responses and outcomes owing to multiple etiologies. Case Report We describe the favorable outcome of salvage immunotherapy using a combination of infliximab and methotrexate in a 62-year-old woman with refractory brainstem encephalitis. The patient was initially presumed to be at a subacute stage of medullary infarction but showed progressively worsening conditions involving cervical myelopathy, despite having completed the schedule of subsequent immunotherapy with intravenous methylprednisolone, immunoglobulin, and rituximab. After completion of four sessions of weekly rituximab injection, she was treated with 5 mg/kg of infliximab, scheduled at 0, 2, and 6 weeks, along with methotrexate (weekly 12.5 mg). After completion of infliximab injection and maintenance with methotrexate treatment, she showed an improving course of quadriplegia. Conclusion This case report provides evidence for the potential efficacy of infliximab with methotrexate in cases of refractory brainstem encephalitis.

Keywords

• brainstem encephalitis
• subacute cerebral infarction
• infliximab
• immunotherapy