1
|
Depreitere J, Antrop I, Verhelst H. Disease course and psychosocial outcome for children and adolescents with anti-N-methyl-D-aspartate receptor encephalitis. Clin Child Psychol Psychiatry 2024; 29:648-660. [PMID: 37915202 DOI: 10.1177/13591045231211963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Explore psychosocial outcome and impact of persisting deficits on quality of life (QoL) and global functioning after anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) in children and adolescents. METHODS Four female patients (age 7-16y) and their caregivers participated in the study. Information was collected from the medical records and the caregivers via a questionnaire. Both the patients and their caregivers were interviewed by means of the structured clinical interview for DSM-5 disorders, junior version (SCID-5 junior). CGAS and mRS scores were defined and the Pediatric Quality of Life Inventory (PedsQL) was used to assess quality of life of patients and caregivers. RESULTS AND CONCLUSION After the acute phase of the disease patients go through a post-acute phase in which several persisting physical, cognitive and psychiatric symptoms gradually resolve during the following months to a year. In long-term follow up these symptoms partly resolved, but deficits persisted on several domains. Psychiatric symptoms, fatigue and mild cognitive deficits were present in three out of four patients at current assessment. In three patients their academic trajectory was altered. These deficits can have an impact on the quality of life and the global functioning of the patients and caregivers.
Collapse
|
2
|
Wouters S, Van Laere K, De Winter FL. [Late recognition of anti-NMDA receptor encephalitis: the effect of a one-track mind in multiple specialties]. Tijdschr Psychiatr 2024; 66:221-225. [PMID: 38650533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Anti-NMDA receptor encephalitis is an auto-immune disorder often presenting with non-specific and heterogeneous neuropsychiatric symptoms at onset. This complicates a quick and accurate diagnosis. However, a tardy diagnosis has a negative impact on morbidity and mortality. We report about a patient with the clinical presentation of a psychotic depression, who was diagnosed with anti-NMDA receptor encephalitis only after a thorough diagnostic work-up. Neurological symptoms were wrongly attributed to the psychiatric syndrome or considered as side-effects of its treatment. We present an overview of clinical aspects of the disorder, distinctive psychiatric symptoms, diagnostic tools, treatment and prognosis.
Collapse
|
3
|
Piña NN, Andresen E. H - 35 Anti-N-Methyl D-Aspartate Receptor (Anti-NMDAR) Encephalitis in a Spanish Monolingual Immigrant Adjudicated Incompetent to Stand Trial. Arch Clin Neuropsychol 2023; 38:1519. [PMID: 37807531 DOI: 10.1093/arclin/acad067.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE Anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis is a rare, recently discovered condition that typically presents initially with psychiatric disturbances followed by neurological and neuropsychological symptoms. Little is known about neuropsychological outcomes with this condition. This poster will expand our knowledge by presenting a monolingual Spanish male who emigrated to the US from Latin America and was arrested on multiple offenses during psychiatric symptom onset of anti-NMDAR encephalitis. METHODS He was diagnosed with anti-NMDAR encephalitis while incarcerated and experienced severe medical complications while hospitalized during the acute phase. He was subsequently adjudicated incompetent to stand trial (ICST) and sent to a state hospital for competency restoration. During the patient's sub-acute recovery phase in the state hospital, he was administered a limited neuropsychological battery in Spanish to characterize his cognitive functioning and assist in the competency restoration process. RESULTS Most cognitive scores were in the below average range, consistent with neuropsychological profiles of anti-NMDAR encephalitis. Virtually all scores on measures of executive functioning were in the exceptionally low range. While immediate and delayed memory were low to below average, recognition memory was qualitatively better. He was diagnosed with major neurocognitive disorder due to anti-NMDAR encephalitis. CONCLUSIONS This case study highlights a case of anti-NMDAR encephalitis with multiple intersecting factors (i.e., immigrant status, monolingual Spanish speaking, < 12 years of education, adjudicated ICST, etc.) that made it difficult to judge the true etiology of the patient's deficits, or even whether some of the weaknesses found actually represent normal cognition given his background and limited availability of appropriate norms.
Collapse
|
4
|
Stawicka E. Anti-NMDA receptor encephalitis – the narrative review of literature with particular regard to pediatric population. Psychiatr Pol 2022; 56:1315-1326. [PMID: 37098200 DOI: 10.12740/pp/142990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
W ostatnich latach znacząco zwiększyła się częstość rozpoznawania zapaleń mózgu o etiologii autoimmunologicznej, zarówno w populacji pacjentów dorosłych, jak i dzieci i młodzieży. Fakt ten jest niewątpliwie związany z dynamicznym rozwojem nowych metod diagnostycznych, jak również postępem wiedzy medycznej. Szczególnym rodzajem spośród powyższych jest zapalenie mózgu z obecnością przeciwciał przeciwko receptorowi NMDA. Ze względu na występujące w tej chorobie objawy charakterystyczne dla zaburzeń psychicznych to właśnie psychiatrzy są często specjalistami, którzy jako pierwsi mają do czynienia z pacjentem z powyższym rozpoznaniem. Diagnostyka różnicowa jest niezmiernie trudna, a diagnoza oparta przede wszystkim na danych z wywiadu oraz stwierdzeniu typowych objawów klinicznych. Dlatego w artykule na podstawie narracyjnego przeglądu literatury baz danych PubMed, EMBASE, oraz biblioteki Cochrane z lat 2007-2021 z użyciem słów kluczowych: „anti-NMDAR encephalitis”, „children”, „adolescents” opisano charakterystyczny przebieg choroby, omówiono badania diagnostyczne służące potwierdzeniu rozpoznania oraz przedstawiono aktualne wytyczne dotyczące leczenia. Ze względu na częstość występowania zapalenie mózgu z przeciwciałami przeciwko receptorowi baz danych PubMed, EMBASE, oraz biblioteki Cochrane NMDA jest chorobą, którą należy brać pod uwagę w diagnostyce różnicowej w codziennej praktyce psychiatrycznej.
Collapse
Affiliation(s)
- Elżbieta Stawicka
- Klinika Neurologii Dzieci i Młodzieży Instytutu Matki i Dziecka w Warszawie
| |
Collapse
|
5
|
Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder which requires multi-disciplinary treatment including immunomodulation therapy. First presentation is most commonly to psychiatric services and continuing psychiatric care is required to treat disabling symptoms, such as behaviour disturbance, psychosis and catatonia. There is minimal available evidence to guide symptomatic treatment and concern for increased sensitivity to antipsychotics complicates traditional approaches. METHODS All cases of cerebrospinal fluid positive anti-NMDAR encephalitis tested in Queensland, Australia were identified. Demographic, clinical and therapeutic data were collected and reviewed by two independent clinicians. Pre-specified variables reflecting possible treatment side effects were compared. RESULTS The majority of the 30 cases (83%) had early psychiatric symptoms and were treated with antipsychotics (67%), average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, there was little improvement in psychosis, affective symptoms or catatonia with antipsychotics alone. In the cases with psychiatric symptoms, there was no significant difference in the rate of occurrence of neurological and autonomic symptoms between cases prescribed and not prescribed antipsychotics. CONCLUSIONS Psychiatric input is imperative for both acute and longer-term management of anti-NMDAR encephalitis. Primary symptomatic treatment should remain immunotherapy and surgery. Antipsychotic medications have particular value in managing agitation and aggression. Potential side effects from antipsychotic treatment are difficult to differentiate from progression of anti-NMDAR encephalitis but there was no evidence in this cohort of increased antipsychotic sensitivity. Treatment with psychotropic medication should be individualised and adjusted during the course of the illness.
Collapse
Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Cullen O'Gorman
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Gemma McKeon
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Andrew Swayne
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Stefan Blum
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| |
Collapse
|
6
|
Panariello A, Bassetti R, Radice A, Rossotti R, Puoti M, Corradin M, Moreno M, Percudani M. Anti-NMDA receptor encephalitis in a psychiatric Covid-19 patient: A case report. Brain Behav Immun 2020; 87:179-181. [PMID: 32454137 PMCID: PMC7255176 DOI: 10.1016/j.bbi.2020.05.054] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Adelaide Panariello
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | - Roberta Bassetti
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | - Anna Radice
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | | | - Massimo Puoti
- Infectious Diseases Unit, Niguarda Hospital, Milan, Italy
| | | | - Mauro Moreno
- Healthcare Management, Niguarda Hospital, Milan, Italy
| | - Mauro Percudani
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy.
| |
Collapse
|
7
|
Abstract
BACKGROUND Anti-NMDA receptor (NMDAr) encephalitis is the most common autoimmune encephalitis in adults. It mimics psychiatric disorders so often that most patients are initially referred to a psychiatrist, and many are misdiagnosed. Without prompt and effective treatment, patients are likely to suffer a protracted course with significant residual disability, or death. This study focuses on the frequency and chronology of salient clinical features in adults with anti-NMDAr encephalitis who are likely to be first evaluated by a psychiatrist because their presentation suggests a primary psychiatric disorder. METHODS A systematic search of PubMed and EMBASE databases identified published reports of anti-NMDAr encephalitis associated with prominent behavioral or psychiatric symptoms. After eliminating redundancies, the frequencies and relative timing of clinical features were tabulated. Signs and symptoms were assigned temporal ranks based on the timing of their first appearance relative to the first appearance of other signs and symptoms in each patient; median ranks were used to compare temporal sequencing of both individual features and major symptom domains. RESULTS Two hundred thirty unique cases (185 female) met study inclusion criteria. The most common features were seizures (60.4%), disorientation/confusion (42.6%), orofacial dyskinesias (39.1%), and mutism/staring (37.4%). Seizures, fever, and cognitive dysfunction were often the earliest features to emerge, but psychiatric features predominated and sequencing varied greatly between individuals. CONCLUSIONS Clinicians should consider anti-NMDAr encephalitis when new psychiatric symptoms are accompanied by a recent viral prodrome, seizures or unexplained fever, or when the quality of the psychiatric symptoms is unusual (e.g. non-verbal auditory hallucinations).
Collapse
Affiliation(s)
- Ronald J Gurrera
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Abstract
Autoimmune encephalitis is a group of autoimmune inflammatory disorders affecting both grey and white matter of the central nervous system. Encephalitis with autoantibodies against the N‑methyl-D-aspartate receptor (NMDA-R) is the most frequent autoimmune encephalitis syndrome presenting with a characteristic sequence of psychiatric and neurological symptoms. Treatment necessitates a close interdisciplinary cooperation. This article provides an update on the current knowledge on diagnostic standards, pathogenesis, and treatment strategies for anti-NMDA-R encephalitis from psychiatric and neurological perspectives.
Collapse
Affiliation(s)
- S Kovac
- Klinik für Allgemeine Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - J Alferink
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - D Ahmetspahic
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - V Arolt
- Cluster of Excellence EXC 1003, Cells in Motion, Universität Münster, Münster, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - N Melzer
- Klinik für Allgemeine Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
| |
Collapse
|
9
|
Abstract
RATIONALE Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an auto-immune and paraneoplastic encephalitis with prominent neuropsychiatric manifestations. The N-methyl-D-aspartate receptor is located in the forebrain and hippocampus and plays a role in learning and memory. PATIENT CONCERNS A 29-year-old female patient with anti-NMDAR encephalitis, was reported and we also reviewed the literature and summarised the characteristics of the cases. DIAGNOSES In the present study, we reported 1 patient with anti-NMDAR encephalitis diagnosed by the detection of anti-NMDAR antibodies in serum and cerebrospinal fluid (CSF). INTERVENTIONS The patient received glucocorticoids and anti-epilepsy treatment as well as human immunoglobulin treatment. OUTCOMES After treatment, the patient gradually regained consciousness and was discharged after 3 months of rehabilitation. At the follow-up 2 months later, the patient had the sequelae of memory impairment and limb movement disorders. LESSONS An accurate early diagnosis and active treatment are crucial to the improvement in the prognosis of patients with anti-NMDAR receptor encephalitis.
Collapse
Affiliation(s)
- Hua Li
- Department of Emergency, Henan Traditional Chinese Medicine Hospital, Zhengzhou, Henan
| | - Yan-ke Guo
- Department of Emergency, Henan Traditional Chinese Medicine Hospital, Zhengzhou, Henan
| | - Ying-lin Cui
- Department of Emergency, Henan Traditional Chinese Medicine Hospital, Zhengzhou, Henan
| | - Tao Peng
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, Shandong, China
| |
Collapse
|
10
|
de Bruijn MAAM, Aarsen FK, van Oosterhout MP, van der Knoop MM, Catsman-Berrevoets CE, Schreurs MWJ, Bastiaansen DEM, Sillevis Smitt PAE, Neuteboom RF, Titulaer MJ. Long-term neuropsychological outcome following pediatric anti-NMDAR encephalitis. Neurology 2018; 90:e1997-e2005. [PMID: 29703768 PMCID: PMC5980521 DOI: 10.1212/wnl.0000000000005605] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/15/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To provide detailed long-term outcome data of children and adolescents following pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, to identify neuropsychological impairments, and to evaluate the influence of these factors on quality of life (QoL). METHODS All Dutch children diagnosed with anti-NMDAR encephalitis were identified. Patients currently aged 4 years or older were included in the follow-up study, consisting of a visit to our clinic for a detailed interview and a standardized neuropsychological assessment. The following domains were included: attention, memory, language, executive functioning, QoL, and fatigue. Primary outcome measures were z scores on sustained attention, long-term verbal memory, QoL, fatigue, and working memory. RESULTS Twenty-eight patients were included. Median Pediatric Cerebral Performance Category at last visit was 1 (interquartile range 1-2, range 1-4), and 64% (18/28) of patients returned consistently to their previous school level. Twenty-two patients were included in the cross-sectional part of the long-term follow-up study. Median follow-up time was 31 months (interquartile range 15-49, range 5-91). There were problems with sustained attention (z = -2.10, 95% confidence interval = -2.71 to -1.46, p < 0.0001) and fatigue (z = -0.96, 95% confidence interval = -1.64 to -0.28, p = 0.008). Cognitive deficits were not correlated with QoL, while fatigue was strongly correlated with QoL (r = 0.82, p < 0.0001). CONCLUSIONS Although follow-up is often reported as "good" following pediatric anti-NMDAR encephalitis, many patients have cognitive problems and fatigue, even up until adolescence, resulting in academic achievement problems and lower QoL. For physicians, it is essential to be aware of these problems, to provide valuable advice to patients and caregivers in the acute and follow-up phase, and to consider early neuropsychological counseling.
Collapse
Affiliation(s)
- Marienke A A M de Bruijn
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Femke K Aarsen
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marielle P van Oosterhout
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke M van der Knoop
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Coriene E Catsman-Berrevoets
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marco W J Schreurs
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Danielle E M Bastiaansen
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter A E Sillevis Smitt
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rinze F Neuteboom
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maarten J Titulaer
- From the Departments of Neurology (M.A.A.M.d.B., D.E.M.B., P.A.E.S.S., M.J.T.), Pediatric Neurology (F.K.A., M.P.v.O., M.M.v.d.K., C.E.C.-B., R.F.N.), and Immunology (M.W.J.S.), Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| |
Collapse
|
11
|
Suleman S, Javed Q. NMDAR (N-methyl-D-aspartate receptor) encephalitis in a patient with MS (multiple sclerosis): a rare and challenging case. BMJ Case Rep 2018; 2018:bcr-2017-222086. [PMID: 29455177 PMCID: PMC5836642 DOI: 10.1136/bcr-2017-222086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 11/04/2022] Open
Abstract
We present a rare case of N-methyl-D-aspartate receptor (NMDAR) encephalitis in a 41-year-old Caucasian woman, who initially presented with prominent neuropsychiatric symptoms on the background of pre-existing multiple sclerosis. Here, the authors navigate the muddy water between neurology and psychiatry, describing the caveats of antibody testing with a misdiagnosed case of acute and transient psychotic episode. NMDAR encephalitis in MS is a rare condition, which can be easily confused with a new onset psychotic episode. This case report can be helpful in recognition and diagnosis of this rare condition. Making the right diagnosis is important since it can prevent an unnecessary radical treatment and long-term neuropsychiatric complications.
Collapse
Affiliation(s)
- Sadia Suleman
- General Adult Psychiatry, Mersey Care NHS Foundation Trust, Liverpool
| | - Qaiser Javed
- Liaison Psychiatry, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
12
|
Restrepo Martínez M, Paola Bautista G, Espínola-Nadurille M, Bayliss L. Red flags for suspecting anti-NMDAr encephalitis in a first psychotic episode: report of two cases. ACTA ACUST UNITED AC 2017; 48:127-130. [PMID: 30981326 DOI: 10.1016/j.rcp.2017.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/22/2017] [Indexed: 11/16/2022]
Abstract
Anti-N-methyl-D-Aspartate receptor (NMDAr) encephalitis is a recently described clinical entity with an increasing number of reported cases. Psychiatric symptoms in the early stages of the disease constitute a diagnostic challenge for the treating physician. We present two clinical cases: clinical case 1, a 26-year-old man, and clinical case 2, an 18-year-old man; both presented with a first episode of psychosis and were hospitalized as psychiatric disorders. Subsequently, both cases were diagnosed as anti-NMDAr encephalitis. The high prevalence of psychiatric symptoms in anti-NMDAr encephalitis forces psychiatrists and neurologists to have a high degree of suspicion in the presence of atypical symptoms in patients evaluated for the first episode of psychosis.
Collapse
Affiliation(s)
| | - G Paola Bautista
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | - Leo Bayliss
- Unidad de Neurología, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| |
Collapse
|
13
|
Zhu WW, Liao WP, Yi YH, Song XW. [Efficacy and safety of cyclophosphamide as a sequential immunotherapy drug for anti-N-methyl-D-aspartate receptor encephalitis in children]. Zhongguo Dang Dai Er Ke Za Zhi 2017; 19:668-671. [PMID: 28606234 PMCID: PMC7390296 DOI: 10.7499/j.issn.1008-8830.2017.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/19/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of cyclophosphamide as a second-line drug in the treatment of children with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. METHODS Six children with anti-NMDAR encephalitis, who showed poor response to steroids and intravenous immunoglobulin, were given cyclophosphamide as a second-line immunotherapy. Follow-up was performed to evaluate the efficacy and safety of cyclophosphamide. RESULTS After first-line immunotherapy for 1-4 weeks, the six patients had reduced psychiatric symptoms, seizures, and involuntary movements; three patients had an improved level of consciousness and were able to make simple conversations. However, all the patients still showed slow response, as well as cortical dysfunction symptoms such as aphasia, alexia, agraphia, acalculia, apraxia, and movement disorders. The six patients continued to receive cyclophosphamide as a sequential therapy. They were able to answer simple questions 7 days after treatment. Three school-aged patients were able to make simple calculation, had greatly improved reading and writing ability, and almost recovered self-care ability 2-3 weeks later. The cognitive function of the six patients was almost restored to the level before the onset of disease, and their living ability returned to normal 2-3 months later. During the treatment period, there were no adverse reactions or abnormal results of routine blood test and liver and kidney function tests. CONCLUSIONS Children with anti-NMDAR encephalitis should be given appropriate immunotherapy as soon as possible. Cyclophosphamide as a sequential therapy has good efficacy and safety.
Collapse
Affiliation(s)
- Wei-Wen Zhu
- Department of Neurology, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.
| | | | | | | |
Collapse
|
14
|
Luna-Lario P, Hernaez-Goni P, Tirapu-Ustarroz J. [Contributions of neuropsychology to anti-NMDA receptor antibody encephalitis: a literature review]. Rev Neurol 2016; 62:415-422. [PMID: 27113067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Limbic encephalitis generated by anti-N-methyl-D-aspartate (NMDA) receptor antibodies is an acute and severe neurological entity, which is more prevalent in young females and is associated to an underlying tumour. Since it leads to severe cognitive impairment, thought needs to be given to the contributions of neuropsychology to the diagnosis, development and treatment of the disease, which have received little attention from researchers to date. A review is conducted of the prior literature, evaluating the measurement of the cognitive symptoms (predominantly mnemonic and executive) associated to this disease. Valid, reliable neuropsychological instruments are proposed, and it is suggested that neuropsychological measures may be used as parameters to follow up these patients which help monitor their functionality in daily living once they have recovered from the acute phase. Similarly they can become a basis on which to assemble rehabilitation programmes that favour the accomplishment of personal autonomy and the patients' reintegration in the community. Nevertheless, we stress the need to include neuropsychologists and neuropsychiatrists in not only the detection but also the treatment of these patients so as to enable them to recover their personal independence and re-adapt to their natural settings.
Collapse
Affiliation(s)
- P Luna-Lario
- Complejo Hospitalario de Navarra.Servicio Navarro de Salud-Fundacion Argibide, Pamplona, Espana
| | | | - J Tirapu-Ustarroz
- Complejo Hospitalario de Navarra. Servicio Navarro de Salud-Fundacion Argibide, Pamplona, Espana
| |
Collapse
|
15
|
Zhou SX, Yang YM. Anti-N-methyl-D-aspartate receptor encephalitis with occult ovarian teratoma: a case report. Int J Clin Exp Pathol 2015; 8:15474-15478. [PMID: 26823917 PMCID: PMC4713703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
A 31-year-old female was admitted with headache, memory disturbance, abnormal behavior, incontinence, confusion, complex partial seizures, decreased oxygen saturation and increased temperature. Anti-NMDAR antibodies were positive in serum and cerebrospinal fluid. Subsequently, a regimen of immunotherapy that included intravenous immunoglobulins, methylprednisolone, plasma exchange and their combinations were used. But the treatment was ineffective. Though both transvaginal ultrasonography and abdominal CT scan contrast revealed left ovarian cyst, the patient had left oophorectomy. And during surgery we found a small cyst mass contained fat-like liquid with air in her left ovarian. Pathological examination demonstrated mature cystic teratoma accompanied with brain tissue. She has made gradual and steady improvement after surgery, but not fully recovery. By combining this case with previous studies of others, we further discuss the clinical characteristics, treatment and prognosis of the disease.
Collapse
Affiliation(s)
- Shi-Xian Zhou
- Department of Geriatrics, The First Affiliated Hospital, School of Medicine, Zhejiang University Hangzhou 310003, Zhejiang, China
| | - Yun-Mei Yang
- Department of Geriatrics, The First Affiliated Hospital, School of Medicine, Zhejiang University Hangzhou 310003, Zhejiang, China
| |
Collapse
|
16
|
McKnight C, Rhoads J, Guirgis H, Duchemin AM. Comment on: Psychiatric Manifestations of Anti-NMDA Receptor Encephalitis: Neurobiological Underpinnings and Differential Diagnostic Implications (Maneta and Garcia, Psychosomatics 2014;55:37-44). Psychosomatics 2015; 56:315-316. [PMID: 25016360 DOI: 10.1016/j.psym.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Curtis McKnight
- Department of Psychiatry, Creighton University School of Medicine, Phoenix, AZ
| | | | - Hossam Guirgis
- Department of Psychiatry, The Ohio State University, Columbus, OH
| | | |
Collapse
|
17
|
Hau L, Csábi G, Tényi T. [Anti-N-methyl-D aspartate receptor encephalitis - guideline to the challenges of diagnosis and therapy]. Psychiatr Hung 2015; 30:402-408. [PMID: 26771699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Anti-N-methyl-D-Aspartate encephalitis is a recently diagnosed autoimmune disorder with increasing significance. During this disease antibodies are produced against the subunit of the NMDA receptor, which cause different symptoms, both psychiatric and neurological. The aim of this publication is to introduce this disease, to facilitate the diagnosis and to recommend therapeutical guideline. MATERIALS AND METHODS In this review we summarized the relevant literature published between 2007 and 2015 giving emphasis on etiopathogenesis, diagnosis, differential diagnosis, treatment and prognosis. RESULTS In the etiology an underlying tumor or a viral agent should be considered. During the disease we can discern 3 periods: first prodromal viral infections-like symptoms can be seen, 1-2 weeks later psychiatric symptoms, such as aggression, sleep and behavior disturbances appear. After that neurological symptoms (tonic-clonic convulsions, aphasia, catatonia, orofacial dyskinesia, autonom lability, altered mental state) are typical, and the patient's condition deteriorates. For the correct diagnosis it is necessary to detect antibodies against the NMDA receptor from the serum and the liquor. Steroids, immunoglobulins and plasmaheresis are the first-line therapies. If the disease is unresponsive, then as a second-line therapy anti-CD 20 (Rituximab) and cyclophosphamid can be useful. Most of the patients are improving without any neurological sequale with prompt detection and appropriate therapy. CONCLUSION It is important to be familiar with the symptoms, diagnosis and therapy of this disease as a practicing clinician, especially as a psychiatrist or neurologist. 75 percentage of the patients are admitted to psychiatric departments first because of the leading symptoms. Autoimmune NMDA encephalitis is a reversible disease after early diagnosis and treatment.
Collapse
Affiliation(s)
- Lídia Hau
- Pecsi Tudomanyegyetem Klinikai Idegtudomanyok Doktori Iskola, Pszichiatria Program, Pecs, Hungary, E-mail:
| | | | | |
Collapse
|
18
|
Kumar R, Gunaratne D, Khan S, Crawford K, Cook M, Tuck R. Acute neuropsychiatric manifestations of anti-N-methyl-D-aspartate receptor encephalitis. Australas Psychiatry 2013; 21:279-80. [PMID: 23720469 DOI: 10.1177/1039856213476122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
19
|
Aoki H, Morita S, Miura N, Tsuji T, Ohnuki Y, Nakagawa Y, Yamamoto I, Takahashi H, Inokuchi S. Early diagnosis of anti-N-methyl-D-aspartate receptor encephalitis in a young woman with psychiatric symptoms. Tokai J Exp Clin Med 2012; 37:89-93. [PMID: 23032251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/30/2012] [Indexed: 06/01/2023]
Abstract
A previously healthy 21-year-old woman, transported to our medical emergency center for excluding organic brain disease, had undergone medical examination 9 days before for trembling in her left hand, which was caused by stress. The patient exhibited fever and strange behaviors, e.g., wandering around, babbling, and making smoking gestures; hence, psychiatric examination was performed. The patient's Glasgow Coma Scale score was 4-3-5, and involuntary movement was observed. Cerebrospinal fluid examination revealed increased cell count; hence, we suspected anti-N-methyl-d-aspartate (NMDA) receptor encephalitis. We conducted an abdominal CT scan, which revealed a neoplastic lesion with calcification in the right ovary. Early steroid pulse therapy was started. On hospital day 25, she tested positive for anti-NMDA receptor antibodies; hence, anti-NMDA receptor encephalitis and concomitant ovarian teratoma was diagnosid. She underwent right adnexectomy; subsequently, immunotherapy was performed. The patient recovered and was discharged on hospital day 105. Anti-NMDA receptor encephalitis is not uncommon; however, this disease must be considered for young encephalitis patients exhibiting psychiatric symptoms. If patients (aged ≤ 30 years) presents with encephalitis of uncertain etiology, psychiatric symptoms, seizures, movement disorders, or psychosis, clinicians should consider anti-NMDA encephalitis as a possible diagnosis. Clinical diagnosis should be waged early to ensure timely treatment.
Collapse
Affiliation(s)
- Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|