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Anti-NMDA receptor encephalitis and other emerging autoimmune brain diseases

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  • #16
    Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

    My son, an Iraq Veteran, has been in the hospital since June 4th for this disease. He had been diagnosed with Post Traumatic Stress Syndrome in December of 2009 and started "not feeling right" in March 2010. He is 22 yrs old.
    He was first diagnosed by the VA with acute psychosis. Kudos to the director of the Psyche ward because he felt there was something medically going on and persisted until NMDA was confirmed and re-confirmed.

    My son has been mostly catatonic and has hallucinations everyday that he is still in Iraq. There has been some progress after undergoing the IVIG and steroid treatment, but not much. He had his first major seizure last Monday and several smaller ones since. He is on 2 different anti-seizure meds, a psyche med, a beta blocker med and Ativan as needed.

    The doctors believe this is as severe a case of NMDA as they have known and read about. I believe there is definately the contributing factor of the PTSD. An interesting side note is that they have done several MRI's and cat scans as well as many other tests and have found no tumors. They say that doesn't mean there is no tumor...they simply may not be finding it.

    So in the case that there is no tumor...how does one pick this disease up or how does it start on it's own?

    Comment


    • #17
      Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

      I'm sorry to hear about what you and your son are going through, Zolt. I haven't heard of any theories proposed by doctors or researchers as to what the underlying cause of the illness is. I'm hoping the CDC is aware of this and will publish a page summarizing what is known soon on their website.

      But this looks like a study showing hope for long term recoveries:

      http://resources.metapress.com/pdf-p...4&size=largest
      Journal of Neurology
      Received: 30 April 2010 Accepted: 17 May 2010 Published online: 2 June 2010
      Abstract
      The long-term neuroimaging correlates of clinical recovery have not been described in anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. The aim of the study is to evaluate the long-term outcome of brain atrophy in anti-NMDAR encephalitis. Patients were two women (ages 17 and 33 years) with severe anti-NMDAR encephalitis resulting in decreased level of consciousness, autonomic instability, hypoventilation, and dyskinesias requiring continuous infusion of anesthetic agents for 6?7 months. Brain MRI and cerebral blood flow SPECT obtained at the time of maximal neurological disability were compared with similar studies obtained 5?7 years later. Both patients were hospitalized for 9?14 months and developed frontotemporal atrophy and hypoperfusion 7?12 months after symptom presentation. In both patients, cognitive functions gradually improved over the next 4?5 years. Comparative neuroimaging studies obtained 5?7 years after symptom presentation showed dramatic improvement of the atrophy and frontotemporal hypoperfusion. The severe and protracted deficits and the frontotemporal atrophy that occur in some patients with anti-NMDAR encephalitis are potentially reversible. This suggests that a functional rather than a structural neuronal damage underlies the pathogenesis of this disorder.
      Here are a couple of successful treatment reports (More contact information in the links, and your doctors may have full text access.):

      http://adc.bmj.com/content/94/4/314....2-d59335546d58
      Arch Dis Child 2009;94:314-316 doi:10.1136/adc.2008.149021

      * Case report

      Successful treatment of anti-N-methyl-D-aspartate receptor encephalitis presenting with catatonia

      1. M Schimmel1,
      2. C G Bien2,
      3. A Vincent3,
      4. W Schenk1,
      5. J Penzien1



      Abstract

      The case of a 12-year-old girl with the typical clinical symptoms of the recently described anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is reported. Within 6 weeks the full clinical spectrum of this condition presented with seizures, agitation, stupor, autonomic instability, dysphagia and hypoventilation leading to a diagnosis of pernicious catatonia. MRI and CSF glucose, protein and lactate were repeatedly normal. EEG revealed rhythmical slowing. No teratoma was detected. Recognition of the unique pattern of the clinical symptoms led to early consideration of this disease which was confirmed by detection of anti-NMDAR antibodies. After high dose prednisolone without clinical improvement, plasmapheresis was followed by a rapid reduction in antibodies and recovery within a few weeks. To our knowledge this is the youngest patient with anti-NMDAR encephalitis to have been described to date. We speculate that NMDAR antibodies may be directly involved in the pathogenesis of this disease.
      http://adc.bmj.com/content/95/4/312....2-d59335546d58
      Arch Dis Child 2010;95:312 doi:10.1136/adc.2009.164889


      Successful treatment of antiN-methyl-d-aspartate receptor limbic encephalitis in a 22-monthold child with plasmapheresis and pharmacological immunomodulation

      1. Shakti Agrawal1,
      2. Angela Vincent2,
      3. Leslie Jacobson2,
      4. David Milford1,
      5. Rajat Gupta1,
      6. Evangeline Wassmer1

      * Accepted 13 September 2009

      We report the case of a previously healthy 22-month-old girl who presented with the full clinical spectrum of anti-N-methyl-daspartate receptor (NMDAR) encephalitis with seizures, agitation, stupor, autonomic instability, dysphagia and relentless choreoathetoid movements.

      Schimmel et al describe a 12-year-old girl with typical clinical symptoms of the recently described NMDAR encephalitis.1 Their patient was the youngest reported case with this condition to date.

      The symptoms in our patient began 1 week after a meningitis C booster vaccination. Cerebrospinal fluid (CSF) examination on admission showed raised lymphocyte count and oligoclonal bands with no oligoclonal bands in a paired blood sample....
      I think there is an urgent need for research into the cause of this serious illness.
      _____________________________________________

      Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

      i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

      (My posts are not intended as advice or professional assessments of any kind.)
      Never forget Excalibur.

      Comment


      • #18
        Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

        I saw a blog comment report of a 2-yr-old with encephalitis symptoms that led to testing for anti-NMDAR encephalitis, but two successive tests came back negative.

        From the new paper below, it looks like there has been the discovery of more forms of autoimmune encephalitis.

        http://www.medscape.com/viewarticle/724627
        From Medscape Medical News
        LGI1 Identified as Autoantigen Associated With Limbic Encephalitis

        Emma Hitt, PhD
        July 6, 2010 ? Researchers have identified LGI1 (leucine-rich, glioma-inactivated 1) rather than voltage-gated potassium channels as the autoantigen associated with limbic encephalitis, a finding that may change diagnosis and classification of the disorder.
        ...
        On the basis of their findings, the study authors suggest that limbic encephalitis should now be classified as an autoimmune synaptic encephalopathy, similar to those associated with NMDA or AMPA receptor antibodies.
        _____________________________________________

        Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

        i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

        (My posts are not intended as advice or professional assessments of any kind.)
        Never forget Excalibur.

        Comment


        • #19
          Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

          Here's a short abstract describing the case of a 3-yr-old who came down with anti-NMDAR encephalitis a month after a respiratory infection.

          http://www.ncbi.nlm.nih.gov/pubmed/20692195
          Eur J Paediatr Neurol. 2010 Aug 5. [Epub ahead of print]
          Anti-NMDA-receptor encephalitis in a 3 year old patient with chromosome 6p21.32 microdeletion including the HLA cluster.

          Verhelst H, Verloo P, Dhondt K, De Paepe B, Menten B, Dalmau J, Van Coster R.

          Department of Paediatric Neurology, Ghent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium.
          _____________________________________________

          Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

          i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

          (My posts are not intended as advice or professional assessments of any kind.)
          Never forget Excalibur.

          Comment


          • #20
            Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

            Full text of a case report of the first patient diagnosed in China. (The patient's serum was sent to the Center for Paraneoplastic Neurological Disorders, University of Pennsylvania for antibody testing.) Since then a couple more cases have been identified in China and they are preparing for more.

            http://www.hkmj.org/article_pdfs/hkm1008p313.pdf
            Hong Kong Med J Vol 16 No 4 August 2010
            Last edited by Emily; September 1, 2010, 06:30 PM. Reason: typo
            _____________________________________________

            Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

            i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

            (My posts are not intended as advice or professional assessments of any kind.)
            Never forget Excalibur.

            Comment


            • #21
              Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

              Case in a 34-yr-old male reported in Australia:

              Started out with flu-like symptoms and a headache, ended up in an induced coma on a ventilator:
              http://www.inspire.com/groups/enceph...-story-so-far/

              Got the diagnosis in the next thread. Note that the mother of one of the patients mentioned earlier in the thread comments and says that her daughter was told she had the flu for a month last year prior to the anti-NMDAR diagnosis:
              http://www.inspire.com/groups/enceph...osis-for-pete/


              The article below shows that there isn't consensus yet on whether this illness is new.

              http://cumc.columbia.edu/features/qu...kable-recovery
              September 1, 2010

              Quick Diagnosis of Rare Disease Leads to Remarkable Recovery

              By Susan Conova
              ….
              When Dr. Lee first saw Annalisa in the neuro ICU, he immediately suspected paraneoplastic anti-NMDAR encephalitis from his previous experiences with the disorder. But they’ve all been recent experiences, which makes some of Annalisa’s doctors wonder if the syndrome is something new and on the rise.

              “I never saw these cases in my training, and once you see this movement disorder, you never forget it,” Dr. Lee says. “I’ve spoken to people with 40 and 50 years of experience, and they’ve said they never saw anything like it in the past. I think it’s something new, but it remains to be seen.”

              Though the syndrome may turn out to be a common cause of encephalitis in young adults and children, Penn’s Dr. Dalmau believes it is simply becoming more recognized by clinicians. “When you look back at some older descriptions of mysterious cases of encephalitis, you realize they could have been describing anti-NMDAR encephalitis,” Dr. Dalmau says. “It’s like the story of the blind men and the elephant. A few different aspects of the disease have probably been described in the past, but now we know the whole elephant.”
              The article below suggests that a disorder described in six children in 1992 as Sebire syndrome may have been anti-NMDAR encephalitis. The article also describes a phase in current cases of anti-NMDAR E where children are having difficulty recovering speech and other social interaction functions. The authors reports that this can be a transition phase that is part of long term recovery, rather than permanent loss of function.
              http://onlinelibrary.wiley.com/doi/1...9.03542.x/full
              Developmental Medicine & Child Neurology Volume 52, Issue 5, pages e78–e82, May 2010
              Last edited by Emily; October 4, 2010, 02:27 AM. Reason: Clarificafition
              _____________________________________________

              Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

              i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

              (My posts are not intended as advice or professional assessments of any kind.)
              Never forget Excalibur.

              Comment


              • #22
                Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                This is a full text article from <em>Neurology</em> describing a case history for a 47-year-old man who was treated with ECT after being diagnosed with anti-NMDAR encephalitis.

                NEUROLOGY 2010;75:e44-e46
                Pearls & Oy-sters: Electroconvulsive therapy in anti-NMDA receptor encephalitis
                H.M.H. Braakman, MD, V.M.P. Moers-Hornikx, MD, B.M.G. Arts, MD, PhD, R.M.M. Hupperts, MD, PhD and J. Nicolai, MD, PhD

                From the Departments of Neurology (H.M.H.B., V.M.P.M.-H., J.N.) and Psychiatry (B.M.G.A.), Maastricht University Medical Center, Maastricht; and Department of Neurology (R.M.M.H.), Orbis Medical Center, Sittard, the Netherlands.
                _____________________________________________

                Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                (My posts are not intended as advice or professional assessments of any kind.)
                Never forget Excalibur.

                Comment


                • #23
                  Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                  Full text article about the case of a young 18-yr-old man with this disease, (in the state of Maryland, USA.)

                  NEUROLOGY 2010;74:e83-e86

                  ? 2010 American Academy of Neurology
                  Resident and Fellow Section
                  Clinical Reasoning:
                  An 18-year-old man with subacute mental status change
                  Daniel Gold, DO, Rebecca Dougherty, MD and Donald Barone, DO
                  ?.The patient had a tracheostomy and a percutaneous gastrostomy (PEG) tube placed. He remained on mechanical ventilation for 1 month. No tumor was identified on PET. He was hospitalized for 7 months and then discharged to rehabilitation, and as of 10 months he still requires 4 antiepileptics for generalized seizures. Repeat body CT scans and testicular ultrasounds have been negative. No surgical exploration has been performed in search of an occult tumor. He receives monthly maintenance IVIg and cyclophosphamide followed by CSF analysis to measure antibody titers, which reportedly continue to decrease?..
                  Another case in a 2-yr-old reported on Inspire.com.
                  http://www.inspire.com/BlessedMommy2...-encephalitis/
                  _____________________________________________

                  Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                  i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                  (My posts are not intended as advice or professional assessments of any kind.)
                  Never forget Excalibur.

                  Comment


                  • #24
                    Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                    Here's another anti-NMDA case in a 35-yr-old woman who had a teratoma. (I read about this on the Facebook support group.)


                    http://www.urmc.rochester.edu/news/s...ex.cfm?id=3011
                    Canandaigua Woman?s Ordeal Illuminates Rare Form of Seizures October 19, 2010
                    The remarkable story of a Canandaigua, N.Y. women who emerged from a more than six month long coma is now being used to educate physicians about how to recognize and treat her extremely rare condition. The elusive source of her uncontrolled seizures, which physicians at the University of Rochester Medical Center (URMC) ultimately traced to ovarian cancer, and her subsequent recovery are the subject of a paper appearing today in the journal Neurology.....
                    And this might be the first case reported where a patient developed anti-NMDAR encephalitis after she had a teratoma removed. She was initially diagnosed with somatoform disorder with psychosis, but fortunately when the anti-NMDAR E was diagnosed she responded to treatment.

                    Military Medicine, Volume 175, Number 8, August 2010 , pp. 616-618(3)
                    Limbic Encephalitis Presenting With Seizures, Anterograde Amnesia, and Psychosis in a Patient Seven Weeks Status Post Immature Ovarian Teratoma
                    _____________________________________________

                    Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                    i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                    (My posts are not intended as advice or professional assessments of any kind.)
                    Never forget Excalibur.

                    Comment


                    • #25
                      Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                      http://onlinelibrary.wiley.com/doi/1.../ana.21928/pdf
                      In Search of Lost Time From “Demonic Possession” to Anti–N-Methyl-DAspartate Receptor Encephalitis
                      Guillaume Se&#180;bire, MD, PhD
                      The fascinating discovery of anti–N-methyl-D-aspartate receptor (NMDAR) pediatric encephalitis creates new connections between past and present, but likely identical, syndromes.1,2 There was first the strange story of a 14-year-old boy admitted in 1949 at the Alexian Brothers Hospital (Saint Louis, MO) for frightening behavioral disturbances (original description attributed to Rev.
                      William S. Bowdern, SJ3). Clinical manifestations included explosive episodes of rage, extreme auto- and heteroaggressivity, speech deterioration, sudden “shouts in unknown tongue,” and bouts of contorted postures into seemingly impossible shapes,” propagating vibrations, and even “movements to surrounding pieces of furniture.” 3 The patient recovered soon after an exorcism procedure.
                      This case report, popularized by the famous novel and movie The Exorcist, presents striking clinical similarities with most manifestations of anti-NMDAR encephalitis....
                      The news below could be related to the increase in anti-NMDAR cases.

                      http://www.nytimes.com/2010/11/13/us/13exorcism.html
                      New York Times
                      By LAURIE GOODSTEIN
                      Published: November 12, 2010
                      There are only a handful of priests in the country trained as exorcists, but they say they are overwhelmed with requests from people who fear they are possessed by the Devil.

                      Now, American bishops are holding a conference on Friday and Saturday to prepare more priests and bishops to respond to the demand. The purpose is not necessarily to revive the practice, the organizers say, but to help Catholic clergy members learn how to distinguish who really needs an exorcism from who really needs a psychiatrist, or perhaps some pastoral care.
                      Last edited by Emily; November 15, 2010, 03:23 AM. Reason: Added NYT article
                      _____________________________________________

                      Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                      i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                      (My posts are not intended as advice or professional assessments of any kind.)
                      Never forget Excalibur.

                      Comment


                      • #26
                        Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                        http://www.nzma.org.nz/journal/abstract.php?id=4335
                        Anti-NMDA-receptor autoimmune encephalitis without neoplasm: a rare condition?
                        Mark Schmiedeskamp, Pietro Cariga, Annemarei Ranta
                        [snip]
                        Here we present two patients seen in a secondary care hospital that presented in quick succession and were not associated with a tumour. To the best of our knowledge these are the first non-paraneoplastic anti-NMDA-receptor encephalitides reported in New Zealand.
                        http://timesfreepress.com/news/2009/...usual-t/?local
                        Thursday, June 11, 2009
                        Chattanooga: Teen has ?miraculous? recovery from unusual tumor disorder
                        By: Emily Bregel
                        In mid-March, Dottie Davis thought something was off when her typically unsentimental 13-year-old daughter sobbed with joy while riding a new horse on the family's farm in Hixson.....
                        Below is an abstract that has a link to a free full text PDF case report that explores why women might be more prone to this disease than men even if they don't have teratomas.

                        http://www.jstage.jst.go.jp/article/..._2167/_article
                        Internal Medicine
                        Vol. 49 (2010) , No. 19 pp.2167-2173
                        Expression of Various Glutamate Receptors Including N-Methyl-D-Aspartate Receptor (NMDAR) in an Ovarian Teratoma Removed from a Young Woman with Anti-NMDAR Encephalitis
                        _____________________________________________

                        Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                        i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                        (My posts are not intended as advice or professional assessments of any kind.)
                        Never forget Excalibur.

                        Comment


                        • #27
                          Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                          Here's a new report from a hospital in Japan:

                          This is about a 10-yr-old girl.
                          http://ukpmc.ac.uk/abstract/MED/20803970
                          Anti-NMDA receptor antibody encephalitis with recurrent optic neuritis and epilepsy

                          Here is an abstract for a retrospective paper seeking to get an idea of the prevalence of anti-NMDAR encephalitis in recent years by testing stored serum and CSF samples. Charts of 505 patients aged 18 to 35 years admitted to the intensive care unit (ICU) at a single institution, (I think in Germany), during a 5-year period were reviewed for criteria of encephalitis of unknown etiology. Six out of seven found to match the criteria were positive for the anti-NMDAR antibodies. Anti-NMDAR encephalitis represented 1% of all patients? admissions to the ICU for any cause in the age group examined:

                          Neurology November 8, 2010 vol. 75 no. 19 1735-1739
                          Retrospective analysis of NMDA receptor antibodies in encephalitis of unknown origin


                          That sounds like a significant portion of ICU admissions, and a professor of neurology with UCSF seems impressed with the numbers and does a professional call to arms in the short Medscape blog article he wrote linked to below. He writes that this is an important syndrome and the ICU cases are only part of the total picture. (You can join Medscape for free to read the article.)


                          Anti-NMDA receptor antibodies in encephalitis
                          Samuel Pleasure, MD, Neurology, 01:29PM Nov 22, 2010
                          _____________________________________________

                          Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                          i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                          (My posts are not intended as advice or professional assessments of any kind.)
                          Never forget Excalibur.

                          Comment


                          • #28
                            Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                            Thank you Emily for this series.

                            Comment


                            • #29
                              Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                              http://www.thelancet.com/journals/la...253-2/fulltext

                              The Lancet Neurology, Volume 10, Issue 1, Pages 63 - 74, January 2011

                              Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis

                              Prof Josep Dalmau MD a, Eric Lancaster MD a, Eugenia Martinez-Hernandez MD a, Prof Myrna R Rosenfeld MD a, Prof Rita Balice-Gordon PhD b

                              Summary
                              Since its discovery in 2007, the encephalitis associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR) has entered the mainstream of neurology and other disciplines. Most patients with anti-NMDAR encephalitis develop a multistage illness that progresses from psychosis, memory deficits, seizures, and language disintegration into a state of unresponsiveness with catatonic features often associated with abnormal movements, and autonomic and breathing instability. The disorder predominantly affects children and young adults, occurs with or without tumour association, and responds to treatment but can relapse. The presence of a tumour (usually an ovarian teratoma) is dependent on age, sex, and ethnicity, being more frequent in women older than 18 years, and slightly more predominant in black women than it is in white women. Patients treated with tumour resection and immunotherapy (corticosteroids, intravenous immunoglobulin, or plasma exchange) respond faster to treatment and less frequently need second-line immunotherapy (cyclophosphamide or rituximab, or both) than do patients without a tumour who receive similar initial immunotherapy. More than 75% of all patients have substantial recovery that occurs in inverse order of symptom development and is associated with a decline of antibody titres. Patients' antibodies cause a titre-dependent, reversible decrease of synaptic NMDAR by a mechanism of crosslinking and internalisation. On the basis of models of pharmacological or genetic disruption of NMDAR, these antibody effects reveal a probable pathogenic relation between the depletion of receptors and the clinical features of anti-NMDAR encephalitis.
                              _____________________________________________

                              Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                              i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                              (My posts are not intended as advice or professional assessments of any kind.)
                              Never forget Excalibur.

                              Comment


                              • #30
                                Re: Anti-NMDA receptor encephalitis: an emerging autoimmune brain disease

                                The 'mystery illness' of the little girl in post #5 was ultimately diagnosed as anti-NMDAR encephalitis. Doctors had suggested surrendering the 3-yr-old to hospice prior to this discovery after extensive treatments, including immune therapies, had failed to improve her condition.

                                Fortunately after being diagnosed, trying a chemo drug has helped and doctors are hoping that in 1-2 years, she will greatly recover.

                                http://www.abqjournal.com/upfront/23...nt04-23-10.htm

                                Here is a more recent article. Both articles mention that the girl was tested for swine flu and numerous other infectious diseases and that genetic testing had been done for other causes.
                                Last edited by Emily; September 26, 2013, 01:35 AM. Reason: Added article
                                _____________________________________________

                                Ask Congress to Investigate COVID Origins and Government Response to Pandemic H.R. 834

                                i love myself. the quietest. simplest. most powerful. revolution ever. ---- nayyirah waheed

                                (My posts are not intended as advice or professional assessments of any kind.)
                                Never forget Excalibur.

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