A 72-year-old woman presented with a 6-week history of gait disturbance and mild disturbance of consciousness. For 9 months, she had been treated for advanced non-small cell lung cancer with atezolizumab. MRI revealed symmetrical high signal in the thalamus bilaterally (figure). She did not have evidence of cancer recurrence or metastases. Serum autoimmune antibodies were absent (anti-AQP4, anti-MOG, anti-amphiphysin, CV2, PNMA2 [Ma2/Ta], Ri, Yo, Hu, recoverin, SOX1, titin, zic4, GAD65, and Tr [DNER]). In the CSF, she had high immunoglobulin G index and positive oligoclonal bands but normal myelin basic protein, absent anti-NMDA receptor and anti-MOG antibodies, and no evidence of infection. Cytology was normal. She was diagnosed with autoimmune encephalitis associated with atezolizumab treatment and treated with steroids and IV immunoglobulin 9 weeks after the onset of symptoms. The size of the lesions decreased after immunotherapy started, but she remained bedridden.
MRI initially showed high signals bilaterally in thalamus on T2-weighted (A), fluid-attenuated inversion recovery (B), and diffusion-weighted images (C), and apparent diffusion coefficient map (D). Lesion size reduced on fluid-attenuated inversion recovery images 3 (E) and 7 weeks (F) after immunotherapy.
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