Management of neuropsychiatric symptoms in anti NMDAR encephalitis: a case report

Year 2024, Volume: 49 Issue: 3, 846 - 850, 30.09.2024

Fatma Subaşı Turğut , Ayşe Aysima Özçelik , Hasan Kılıç , Mehmet Karadağ

https://doi.org/10.17826/cumj.1381594

Abstract

Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is recognized as the most commonly diagnosed autoimmune encephalitis and is one of the most common causes of encephalitis. A wide spectrum of symptoms such as psychosis, catatonia, behavioral and memory changes, seizures, abnormal movements and autonomic dysregulation usually requires a multidisciplinary treatment approach.Early recognition and prompt initiation of immunotherapy improves patient outcomes.We present a case of a 16-year-old female who had seizures and later had catatonia and psychotic symptoms.Our patient was treated with Rituxumab when he did not get enough benefit from the first-line treatments. Significant improvement in both neurological and psychiatric symptoms occurred after rituxumab treatment.This case highlights the importance of multidisciplinary approach in patients with NMDAR encephalitis and the importance of early transition to second-line treatments in patients who do not respond adequately to first-line treatments. It is aimed to draw attention to the fact that early diagnosis and treatment can dramatically improve neuropsychiatric symptoms, and therefore clinicians should definitely remember NMDAR encephalitis in the differential diagnosis.

Keywords

Autoimmune Encephalitis , Psychosis , NMDAR

Anti NMDAR ensefalitinde nöropsikiyatrik semptomların yönetimi: olgu sunumu

Abstract

Anti-N-Metil-D-Aspartat reseptör (NMDAR) ensefaliti, en sık teşhis edilen otoimmün ensefalit olarak kabul edilmektedir ve ensefalitin en yaygın nedenlerinden biridir. Psikoz, katatoni, davranış ve hafıza değişiklikleri, nöbetler, anormal hareketler ve otonomik disregülasyon gibi geniş bir semptom yelpazesi genellikle multidisipliner bir tedavi yaklaşımı gerektirir. Erken tanı ve immünoterapinin hızlı bir şekilde başlatılması hasta sonuçlarını iyileştirir. 16 yaşında nöbet geçiren ve daha sonra katatoni ve psikotik semptomları olan bir kız olguyu sunuyoruz. Hastamız ilk basamak tedavilerden yeterince fayda görmeyince Rituxumab ile tedavi edildi. Rituxumab tedavisi sonrasında hem nörolojik hem de psikiyatrik semptomlarda belirgin düzelme meydana gelmiştir. Bu vaka, NMDAR ensefaliti olan hastalarda multidisipliner yaklaşımın önemini ve birinci basamak tedavilere yeterli yanıt vermeyen hastalarda ikinci basamak tedavilere erken geçişin önemini vurgulamaktadır. Erken tanı ve tedavinin nöropsikiyatrik semptomları dramatik bir şekilde iyileştirebileceğine ve bu nedenle klinisyenlerin ayırıcı tanıda NMDAR ensefalitini mutlaka hatırlamaları gerektiğine dikkat çekmek amaçlanmıştır.

Keywords

Otoimmun Ensefalit , Psikoz , NMDAR

Ethical Statement

Since it was a case report, we did not obtain an ethics committee, but we obtained a consent form from the patient and included it in the submission.

Supporting Institution

This article has not funding.

Thanks

We would like to thank the patient and his parents for their permission to publish the case report.

References

• Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol. 2011;10:63-74.
• Florance NR, Davis RL, Lam C, Szperka C, Zhou L, Ahmad S et al. Anti–N‐methyl‐D‐aspartate receptor (NMDAR) encephalitis in children and adolescents. Ann Neurol. 2009;66:11-8.
• Dalmau J, Tüzün E, Wu Hy, Masjuan J, Rossi JE, Voloschin A et al. Paraneoplastic anti–N‐methyl‐D‐aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol. 2007;61:25-36.
• Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J. Frequency and characteristics of isolated psychiatric episodes in anti–N-methyl-d-aspartate receptor encephalitis. JAMA Neurol. 2013;70:1133-9.
• Titulaer MJ, McCracken L, Gabilondo I et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. Lancet Neurol. 2013;12:157-65.
• Dalmau J, Gleichman AJ, Hughes EG et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol. 2008;7:1091-8.
• Gitiaux C, Simonnet H, Eisermann M et al. Early electro-clinical features may contribute to diagnosis of the anti-NMDA receptor encephalitis in children. Clin Neurophysiol. 2013;124:2354-61.
• Kuppuswamy PS, Takala CR, Sola CL. Management of psychiatric symptoms in anti-NMDAR encephalitis: a case series, literature review and future directions. Gen Hosp Psychiatry. 2014;36:388-91.
• Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis in psychiatry. Curr Psychiatry Rev. 2011;7:189-93.
• Miya K, Takahashi Y, Mori H. Anti-NMDAR autoimmune encephalitis. Brain Dev. 2014;36:645-52.