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Hansen N, Bartels C, Teegen B, Wiltfang J, Malchow B. Catatonic Schizophrenia Associated With Cerebrospinal GAD65 Autoantibodies: Case Report and Literature Review. Front Immunol 2022; 13:829058. [PMID: 35222413 PMCID: PMC8864160 DOI: 10.3389/fimmu.2022.829058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/10/2022] [Indexed: 01/16/2023] Open
Abstract
Background GAD65 autoimmunity is reported to be associated with schizophrenia and bipolar disorder. However, there has been no evidence that glutamic acid decarboxylase 65 (GAD65) autoantibodies in cerebrospinal fluid (CSF) are associated with akinetic catatonia in schizophrenia patients. Methods We report the case of a 28-year-old man who underwent diagnostics including brain MRI, neuropsychological testing, and electroencephalography (EEG) as well as a tumor search via CT of the abdomen and thorax, as well as colonoscopy and gastroscopy. For clinical characterization, his patient files were retrospectively examined. Results Our patient presented catatonia that responded somewhat to benzodiazepines in combination with previously taken antipsychotics such as risperidone for prediagnosed paranoid schizophrenia. Diagnostics revealed GAD65 autoantibodies in his serum and CSF. MRI revealed no brain lesion, and the tumor search had no malignancy. We diagnosed catatonic schizophrenia. Furthermore, as he had not fully recovered, he was given immunotherapy entailing two cycles of intravenous immunoglobulins. Subsequent neuropsychological testing due to subjective cognitive complaints after immunotherapy revealed no objective cognitive deficits. Conclusions We present the novel finding of an association between GAD65 autoantibodies in the serum and CSF with catatonia in a patient suffering from prediagnosed chronic schizophrenia. Due to the presence of CSF GAD65 antibodies and the catatonia factor in prediagnosed schizophrenia, we suspect that his catatonia has an autoimmune origin. Immunotherapy stabilized the catatonia that had initially responded to lorazepam treatment. Further research should be done to characterize patients' responses to immunotherapy and standard treatment in a large cohort of patients with GAD65 antibody-associated catatonia and schizophrenia.
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Affiliation(s)
- Niels Hansen
- Department of Psychiatry and Psychotherapy, Medical University Center Göttingen, Göttingen, Germany
| | - Claudia Bartels
- Department of Psychiatry and Psychotherapy, Medical University Center Göttingen, Göttingen, Germany
| | | | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, Medical University Center Göttingen, Göttingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), Göttingen, Germany.,Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, Medical University Center Göttingen, Göttingen, Germany
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Taib NIA, Wahab S, Khoo CS, Tan HJ, Kamaruzaman L, Woon LSC, Gan LLY. Case Report: Cotard's Syndrome in Anti-N-methyl D-aspartate (NMDA) Receptor (Anti-NMDAR) Encephalitis. Front Psychiatry 2022; 13:779520. [PMID: 35599755 PMCID: PMC9114484 DOI: 10.3389/fpsyt.2022.779520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 03/25/2022] [Indexed: 12/23/2022] Open
Abstract
Cotard's syndrome is uncommon psychopathology among patients with psychotic illnesses. Limited cases had been reported regarding the occurrence of this syndrome in anti-NMDAR encephalitis which itself is a relatively new disease that often presents with florid psychotic symptoms. This poses difficulties in differentiating it from a primary psychiatric illness. Late recognition of anti-NMDAR encephalitis can lead to death as it can progress to autonomic instability in its natural course of illness. We report a patient who first presented with psychotic symptoms with initial negative findings from baseline investigations. Further investigation revealed anti NMDAR antibodies in the cerebrospinal fluid. Prompt treatment was initiated and despite early poor response to the first-line treatment with the development of allergic reaction, our patient recovered completely after 1 month of hospitalization. This case report aims to highlight the importance of early detection of anti-NMDAR encephalitis and the possibility of uncommon psychopathology such as Cotard's syndrome occurring in this disease.
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Affiliation(s)
- Nur Iwana Abdul Taib
- Department of Psychological Medicine, Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Suzaily Wahab
- Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ching Soong Khoo
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Lydia Kamaruzaman
- Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Luke Sy-Cherng Woon
- Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Lydia Lay Yen Gan
- Department of Pharmacy, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
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3
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Abstract
Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.
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4
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Serra-Mestres J, Villagrasa-Blasco B, Thacker V, Jaimes-Albornoz W, Sharma P, Isetta M. Catatonia in N-methyl-d-aspartate receptor antibody encephalitis: Phenomenological characteristics from a systematic review of case reports. Gen Hosp Psychiatry 2020; 64:9-16. [PMID: 32070914 DOI: 10.1016/j.genhosppsych.2020.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To ascertain the phenomenological characterisation of catatonia in N-methyl-d-aspartate receptor antibody encephalitis (NMDAr-AbE). METHODS A systematic review of case reports was undertaken in accordance with PRISMA guidelines. Case reports of NMDAr-AbE containing sufficient information on the cases' clinical presentation and meeting the study's inclusion criteria were selected. Cases were searched for clinical data in keeping with core catatonic signs by applying the screening instrument of the Bush-Francis Catatonia Rating Scale. When two or more core signs were ascertained catatonia was considered to be present. RESULTS 2645 records were identified through the database search. Following screening and application of eligibility/inclusion criteria 139 articles were selected reporting on 189 individual subjects. Catatonia was present in 60% of these cases. The most prevalent signs were immobility/stupor (70%), mutism (67%), excitement (50%), posturing/catalepsy (34%), stereotypies (31%), and rigidity (30%). Immobility/stupor and excitement co-occurred in the same patient in 33% of cases. CONCLUSION The phenomenological profile of catatonia in this sample of cases of NMDAr-AbE was characterised by a preponderance of signs in the hypokinetic spectrum. However, excitement often co-occurred in these patients suggesting that fluctuations in catatonic semiology may be frequent.
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Affiliation(s)
- Jordi Serra-Mestres
- Department of Old Age Psychiatry, Central & North West London NHS Foundation Trust, Woodland Centre, Hillingdon Hospital, Uxbridge UB8 3NN, UK.
| | - Beatriz Villagrasa-Blasco
- Àrea de Psicogeriatria, Benito Menni CASM, C/Dr. Pujades 38, 08830 Sant Boi de Llobregat, Catalunya, Spain
| | - Vikram Thacker
- Trust, Abraham Cowley Unit, Holloway Hill, Lyne, Chertsey, Surrey, KT16 0AE, UK
| | - Walter Jaimes-Albornoz
- Psychiatry Service, Hospital Universitario Donostia, Begiristain Doktorea Pasealekua 109, 20014 Donostia-San Sebastian, Basque Country, Spain
| | - Puja Sharma
- Department of Old Age Psychiatry, Central & North West London NHS Foundation Trust, Woodland Centre, Hillingdon Hospital, Uxbridge UB8 3NN, UK
| | - Marco Isetta
- Library and Knowledge Services, Central & North West London NHS Foundation Trust, St Charles' Hospital, 125 Exmoor Street, London W10 6DZ, UK
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Fricchione G, Beach S. Cingulate-basal ganglia-thalamo-cortical aspects of catatonia and implications for treatment. HANDBOOK OF CLINICAL NEUROLOGY 2019; 166:223-252. [PMID: 31731912 DOI: 10.1016/b978-0-444-64196-0.00012-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The catatonic syndrome is an example of a multifactorial neurobehavioral disorder that causes much morbidity and mortality but also has the potential to unlock the mystery of how motivation and movement interact to produce behavior. In this chapter, an attempt is made to understand better the catatonic syndrome through the lens of neurobiology and neuropathophysiology updated by recent studies in molecular biology, genomics, inflammasomics, neuroimaging, neural network theory, and neuropsychopathology. This will result in a neurostructural model for the catatonic syndrome that centers on paralimbic regions including the anterior and midcingulate cortices, as they interface with striatal and thalamic nodes in the salience decision-making network. Examination of neurologic disorders like the abulic syndrome, which includes in its extreme catatonic form, akinetic mutism, will identify the cingulate cortex and paralimbic neighbors as regions of interest. This exploration has the potential to unlock mysteries of the brain cascade from motivation to movement and to clarify catatonia therapeutics. Such a synthesis may also help us discern meaning inherent in this complex neurobehavioral syndrome.
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Affiliation(s)
- Gregory Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Scott Beach
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Mané-Damas M, Hoffmann C, Zong S, Tan A, Molenaar PC, Losen M, Martinez-Martinez P. Autoimmunity in psychotic disorders. Where we stand, challenges and opportunities. Autoimmun Rev 2019; 18:102348. [PMID: 31323365 DOI: 10.1016/j.autrev.2019.102348] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/24/2022]
Abstract
Psychotic disorders are debilitating mental illnesses associated with abnormalities in various neurotransmitter systems. The development of disease-modifing therapies has been hampered by the mostly unknown etiologies and pathophysiologies. Autoantibodies against several neuronal antigens are responsible for autoimmune encephalitis. These autoantibodies disrupt neurotransmission within the brain, resulting in a wide range of psychiatric and neurologic manifestations, including psychosis. The overlap of symptoms of autoimmune encephalitis with psychotic disorders raised the question as to whether autoantibodies against a number of receptors, ion channel and associated proteins could ultimately be responsible for some forms of psychosis. Here we review our current knowledge, on antibody mediated autoimmunity in psychotic disorders, the different diagnostic methods and their limitations, as well as on varying therapeutic approaches targeting the immune system.
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Affiliation(s)
- Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Shenghua Zong
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Amanda Tan
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Peter C Molenaar
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Mario Losen
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
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Palakkuzhiyil N, Uvais NA, Moideen S, Shihabudheen P. Anti-NMDA-receptor encephalitis presenting with catatonia in a middle aged male. Asian J Psychiatr 2018; 35:26-27. [PMID: 29729646 DOI: 10.1016/j.ajp.2018.04.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/23/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Naseem Palakkuzhiyil
- Department of Neurology, Iqraa International Hospital and Research Centre, Calicut, Kerala, India.
| | - N A Uvais
- Department of psychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India.
| | - Shamsudeen Moideen
- Department of Internal medicine, Iqraa International Hospital and Research Centre, Calicut, Kerala, India.
| | - P Shihabudheen
- Department of Medicine, Iqraa International Hospital and Research Centre, Calicut, Kerala, India.
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Progressive Encephalomyelitis With Rigidity and Myoclonus Syndrome Presenting as Catatonia. PSYCHOSOMATICS 2018; 60:83-87. [PMID: 30143326 DOI: 10.1016/j.psym.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/30/2022]
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Molecular hypotheses to explain the shared pathways and underlying pathobiological causes in catatonia and in catatonic presentations in neuropsychiatric disorders. Med Hypotheses 2018. [DOI: 10.1016/j.mehy.2018.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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10
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations. METHODS Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar. RESULTS Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized. CONCLUSION Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.
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Evaluation and Management of Autoimmune Encephalitis: A Clinical Overview for the Practicing Child Psychiatrist. Child Adolesc Psychiatr Clin N Am 2018; 27:37-52. [PMID: 29157501 DOI: 10.1016/j.chc.2017.08.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical conditions that present with psychiatric symptoms are becoming increasingly well-recognized in response to the emergence of the field of neuroimmunology. As the availability of testing for novel antineuronal antibodies has increased, so too has the clinical awareness of this diagnostic spectrum. Psychiatrists may have little exposure to this area of expertise, yet may be called on to assist in the diagnosis and treatment of patients with complex neuropsychiatric syndromes secondary to autoimmune encephalitis. This article summarizes the evaluation and management of patients with autoimmune encephalitis and describes emerging patterns in phenotype recognition.
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303952 DOI: 10.1097/pra.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent. J Psychiatr Pract 2017; 23:441-445. [PMID: 29303953 DOI: 10.1097/pra.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
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New Onset Insomnia in a Pediatric Patient: A Case of Anti-NMDA Receptor Encephalitis. Case Rep Pediatr 2017; 2017:4083785. [PMID: 28770118 PMCID: PMC5523231 DOI: 10.1155/2017/4083785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/18/2017] [Accepted: 06/05/2017] [Indexed: 12/13/2022] Open
Abstract
Anti-NMDAR encephalitis is becoming more widely recognized as a cause of encephalopathy in both adults and children. Certain clinical features such as mood lability, movement disorders, speech dysfunction, seizures, and autonomic instability in a pediatric patient should prompt immediate concern and evaluation for autoimmune encephalitis among providers. We present the case of a pediatric patient with anti-NMDAR encephalitis in which the symptom prompting medical evaluation was insomnia. Insomnia has not previously been emphasized in the literature as a presenting feature of this disease in children and has a broad differential. Recognition of the symptoms of anti-NMDAR encephalitis and its variable presentation are key to early diagnosis and prompt initiation of treatment which may help to improve outcomes.
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Psychosis and catatonia as presenting features of anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis. Asian J Psychiatr 2017; 27:112. [PMID: 28558879 DOI: 10.1016/j.ajp.2017.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 02/18/2017] [Indexed: 11/20/2022]
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Weaver M, Griffey RT. Anti-N-Methyl-d-Aspartate Receptor Encephalitis as an Unusual Cause of Altered Mental Status in the Emergency Department. J Emerg Med 2016; 51:136-9. [PMID: 27301666 DOI: 10.1016/j.jemermed.2016.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate (NMDA) receptor autoimmune encephalitis is a newly identified form of encephalitis whose incidence is on the rise. Awareness of this condition and symptom recognition are key to early diagnosis and prompt treatment, which may alter the course of the disease. CASE REPORT A 35-year-old woman presented to our Emergency Department (ED) with lethargy, bizarre behavior, agitation, confusion, memory deficits, and word-finding difficulties. Her symptoms and evaluation were potentially consistent with a primary psychiatric disorder, but the absence of frank psychosis and presence of neurologic features related to memory and cognition prompted other considerations. In the ED we performed a lumbar puncture, and in addition to routine studies, ordered anti-NMDAR antibody screening. The screening studies returned positive, leading to treatment with glucocorticoids and intravenous immune globulin and resulting in improvement to near baseline function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although anti-NMDAR encephalitis is relatively uncommon, reports of this previously unrecognized condition are increasing, with an unclear true incidence of disease. Emergency providers should consider this diagnosis in their differential for patients presenting with new neuropsychiatric symptoms, particularly in young women. Prompt treatment leads to near complete neurologic recovery in 75% of patients, whereas delays in diagnosis and treatment may be associated with worse outcomes including death.
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Affiliation(s)
- Michael Weaver
- Barnes-Jewish Hospital, Washington University School of Medicine, Saint Louis, Missouri
| | - Richard T Griffey
- Barnes-Jewish Hospital, Washington University School of Medicine, Saint Louis, Missouri
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Fischer CE, Golas AC, Schweizer TA, Munoz DG, Ismail Z, Qian W, Tang-Wai DF, Rotstein DL, Day GS. Anti N-methyl-D-aspartate receptor encephalitis: a game-changer? Expert Rev Neurother 2016; 16:849-59. [PMID: 27123777 DOI: 10.1080/14737175.2016.1184088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an inflammatory disorder of the brain that has garnered significant interest within the medical and lay communities. There is a need for formal guidelines to assist physicians in identifying patients who should undergo testing for NMDAR encephalitis, recognizing the high potential for this potentially treatable disease to mimic more common disorders, and consequently remain undiagnosed. AREAS COVERED This review highlights the impact of the discovery of NMDAR encephalitis on the fields of neurology and psychiatry, and discusses the steps that are necessary to improve recognition and treatment of NMDAR encephalitis. Expert commentary: While much progress has been made in our understanding of NMDAR encephalitis, much work remains to be done to delineate the underlying disease mechanisms and their relevance to brain function.
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Affiliation(s)
- Corinne E Fischer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,c Faculty of Medicine, Department of Psychiatry , University of Toronto , Toronto , ON , Canada
| | - Angela C Golas
- d Department of Psychiatry , University of Toronto, Geriatric Psychiatry Subspecialty , Toronto , ON , Canada
| | - Tom A Schweizer
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada.,e Institute of Biomaterials and Biomedical Engineering , University of Toronto , Toronto , ON , Canada.,f Division of Neurosurgery, Department of Surgery, Faculty of Medicine , University of Toronto , Toronto , ON , Canada.,g Division of Neurosurgery , St. Michael's Hospital , Toronto , ON , Canada
| | - David G Munoz
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,h Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , ON , Canada.,i Division of Pathology, Department of Laboratory Medicine and Pathobiology , St. Michael's Hospital , Toronto , ON , Canada
| | - Zahinoor Ismail
- j Hotchkiss Brain Institute , University of Calgary , Calgary , AB , Canada
| | - Winnie Qian
- a Keenan Research Centre for Biomedical Research , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , ON , Canada.,b Institute of Medical Sciences , University of Toronto , Toronto , ON , Canada
| | - David F Tang-Wai
- k Department of Medicine (Neurology and Geriatric Medicine) , University of Toronto , Toronto , ON , Canada.,l UHN Memory Clinic , Toronto Western Hospital , Toronto , ON , Canada
| | - Dalia L Rotstein
- m Department of Medicine (Neurology) , University of Toronto, St. Michael's Hospital , Toronto , ON , Canada
| | - Gregory S Day
- n Knight Alzheimer Disease Research Center, Department of Neurology , Washington University in St. Louis , St. Louis , MO , Canada
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Odiari EA, Sekhon N, Han JY, David EH. Stabilizing and Managing Patients with Altered Mental Status and Delirium. Emerg Med Clin North Am 2015; 33:753-64. [DOI: 10.1016/j.emc.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Abstract
We describe the case of a 17-year-old male who presented with acute onset of seizures and malignant catatonia with psychosis, agitation, and hypermetabolism, who responded to electroconvulsive therapy (ECT). Soon after he began to respond, he was diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and then given immunosuppressive therapy. Anti-NMDA receptor encephalitis is an increasingly recognized autoimmune disorder that often presents with neuropsychiatric symptoms. The mainstays for treatment have been early diagnosis, tumor work-up and removal if found, and initiation of immunosuppressive therapy. Treatment response is often slow and residual symptoms common. In this case, ECT produced clinical stabilization before the underlying diagnosis of anti-NMDA receptor encephalitis was made and standard treatment initiated. We suggest that ECT may be highly beneficial for stabilizing life-threatening neuropsychiatric symptoms in this syndrome and should be considered as a potentially additive treatment to immunotherapy when rapid relief is sought.
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20
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Recognition and Treatment of Anti-N-Methyl-d-Aspartate Receptor Encephalitis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2015. [DOI: 10.1016/j.cpem.2015.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Affiliation(s)
- Lloyd Bradley
- Donald Wilson House Neurological Rehabilitation Centre, Western Sussex Hospitals Trust, Chichester, West Sussex, UK
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Dong TS, Henry JT, Stanley K, Pannain S. Catatonia Induced by an ACTH-Secreting Neuroendocrine Tumor: A Case Report. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14431.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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23
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DeSena AD, Greenberg BM, Graves D. Three phenotypes of anti-N-methyl-D-aspartate receptor antibody encephalitis in children: prevalence of symptoms and prognosis. Pediatr Neurol 2014; 51:542-9. [PMID: 25070939 DOI: 10.1016/j.pediatrneurol.2014.04.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-N-methyl-d-aspartate (NMDA) receptor antibody encephalitis is becoming an increasingly recognized cause of encephalopathy in individuals previously presumed to have viral encephalitis. Various manifestations of this disease include altered mental status, behavioral changes, seizures, and movement disorders. We have noted three distinct subtypes of this disease which appear to have differential responses to immunotherapies and differences in prognosis. METHODS AND PATIENTS We report eight patients observed at our children's hospital from 2009 through 2013 who appear to clearly fall into one of our three clinical categories. To find comparable articles reflecting this classification, we then performed a MEDLINE search of all articles involving the subject heading "anti-NMDA receptor encephalitis" or just the keyword phrase "NMDA encephalitis," and we found 162 articles to review. Twenty-two articles were eliminated due to basic science, and we were able to review 105 of the remaining articles, most of which were case reports or case series, although a few were larger reviews. For the sake of our review, we defined type 1 or "classic" anti-NMDA receptor antibody encephalitis as having a duration of <60 days and being characterized predominantly by a catatonic or stuporous state, type 2 or psychiatric-predominant anti-NMDA receptor antibody encephalitis as having no noteworthy catatonic or stuporous state in addition to the presence of predominantly behavioral and psychiatric symptoms, and type 3 or catatonia-predominant anti-NMDA receptor antibody encephalitis as having a duration of ≥60 days in a predominantly catatonic or stuporous state. RESULTS We note that the poorest responders, even to aggressive immunotherapies, are the patients with catatonia-persistent type anti-NMDA receptor antibody encephalitis, which has, as its hallmark, prolonged periods of severe encephalopathy. Patients with predominantly psychiatric symptoms, which we call the psychiatric-predominant anti-NMDA receptor antibody encephalitis, have had excellent responses to plasma exchange or other immunotherapies and appear to have the least residual deficits at follow-up. Patients with fairly equal representations of periods of altered mental status, behavioral problems, and movement disorders appear to have an intermediate prognosis and likely require early aggressive immunotherapy. CONCLUSIONS In our series, we discuss representative examples of these clinical subtypes and their associated outcomes, and we suggest that tracking these subtypes in future cases of anti-NMDA receptor antibody encephalitis might lead to better understanding and better risk stratification with regard to immunotherapy decisions.
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Affiliation(s)
- Allen D DeSena
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas
| | - Benjamin M Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas
| | - Donna Graves
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, Children's Medical Center Dallas, Dallas, Texas.
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Severe complication of catatonia in a young patient with Hashimoto's encephalopathy comorbid with Cornelia de Lange syndrome. Kaohsiung J Med Sci 2014; 31:60-1. [PMID: 25600923 DOI: 10.1016/j.kjms.2014.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/07/2014] [Accepted: 06/12/2014] [Indexed: 11/24/2022] Open
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25
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Kusztal M, Piotrowski P, Mazanowska O, Misiak B, Kantorska-Janiec M, Boratyńska M, Klinger M, Kiejna A. Catatonic episode after kidney transplantation. Gen Hosp Psychiatry 2014; 36:360.e3-5. [PMID: 24559791 DOI: 10.1016/j.genhosppsych.2014.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 12/30/2013] [Accepted: 01/07/2014] [Indexed: 11/16/2022]
Abstract
There is a growing body of case reports of catatonic symptoms after organ transplantations. A considerable number of these cases might be attributed to neurotoxicity induced by immunosuppressive medications. However, the etiology of other cases remains unclear. We present the case of a 21-year-old woman who developed catatonia after kidney transplantation from a deceased donor. In this case, nontoxic tacrolimus levels were found, and other causal factors including infections, uremia or transplant rejection were excluded. Electroconvulsive therapy followed by olanzapine proved to be effective treatment.
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Affiliation(s)
- Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland.
| | | | - Oktawia Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Błażej Misiak
- Department of Psychiatry, Wroclaw Medical University, Poland; Department of Genetics, Wroclaw Medical University, Poland
| | | | - Maria Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Andrzej Kiejna
- Department of Psychiatry, Wroclaw Medical University, Poland
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26
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Shiner E, Taylor L, Mohan A, Watson S, Sachdev PS. Severe depression masquerading as Creutzfeldt-Jakob disease. BMJ Case Rep 2014; 2014:bcr-2013-203352. [PMID: 24748140 DOI: 10.1136/bcr-2013-203352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report a case of melancholic depression with catatonic features presenting as a rapidly progressive organic brain syndrome, initially thought to be probable Creutzfeldt-Jakob disease. The case highlights the fundamental importance of thorough exclusion of treatable pathology masquerading as an irreversible syndrome.
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Affiliation(s)
- Elizabeth Shiner
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
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27
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Deakin J, Lennox BR, Zandi MS. Antibodies to the N-methyl-D-aspartate receptor and other synaptic proteins in psychosis. Biol Psychiatry 2014; 75:284-91. [PMID: 23988024 DOI: 10.1016/j.biopsych.2013.07.018] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/01/2013] [Accepted: 07/17/2013] [Indexed: 02/06/2023]
Abstract
This review concentrates on the evidence for autoantibodies to cell surface synaptic proteins in psychosis and schizophrenia. We and others have recently found antibodies to the N-methyl-D-aspartate receptor in first-episode psychosis. We describe the evidence for pathogenicity and disease-relevance of these antibodies, which builds on the novel field in neuroimmunology of cell surface antibody-associated central nervous system disorders. Relevant autoantibodies in psychosis and schizophrenia are likely to be those directed to cell surface proteins, in which the likelihood of pathogenicity is greater. We discuss the evidence for this from the field of paraneoplastic neurologic syndromes and the discovery of novel cell surface antigen central nervous system autoimmune syndromes.
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Affiliation(s)
- Julia Deakin
- Department of Psychiatry, University of Cambridge, Cambridge
| | | | - Michael S Zandi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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28
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Seroprevalence of anti-N-methyl-d-aspartate receptor antibodies in women with ovarian teratoma. J Neurol 2013; 260:2831-5. [DOI: 10.1007/s00415-013-7074-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 08/06/2013] [Accepted: 08/07/2013] [Indexed: 01/12/2023]
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