Emergency Department Presentations of Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Anti-N-Methyl-D-Aspartate Receptor Encephalitis Associated with Mature Ovarian Teratoma in a Young Adolescent: A Case Report

BACKGROUND

Ovarian teratoma has an uncommon association with anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. This is a life-threatening condition, and here, we describe a case of an adolescent girl with anti-NMDAR encephalitis caused by an ovarian teratoma.

CASE

A 14-year-old girl presented with acute features of fever, severe headache, altered behavioral changes, delirium, autonomic instability, episodes of seizure, and involuntary movement over a period of 1 month. Upon investigation, electroencephalogram (EEG), computed tomography (CT), and magnetic resonance imaging (MRI) of her brain showed normal findings. Her serum and cerebrospinal fluid were positive for anti-NMDARs, and a diagnosis of anti-NMDAR encephalitis was made, so she received a course of intravenous methyl prednisolone and immunoglobulin and was discharged after her neurological status improved. Upon further workup, she was suspected to have a left ovarian dermoid cyst on transabdominal ultrasonogram, which was an incidental finding. Her tumor marker panel showed normal serum lactate dehydrogenase, beta human chorionic gonadotropin, inhibin, alpha-fetoprotein, and carcinoembryonic antigen and a cancer antigen 125 level of 71.5 U/L. She eventually underwent laparoscopic left ovarian cystectomy and received immunotherapy in the postoperative period. She was discharged in stable condition on postoperative day 4. On histopathological examination, the specimen revealed a mature cystic teratoma with glial component. One year after surgery, the patient has recovered completely and has no residual psychiatric or neurological symptoms.

CONCLUSION

Complete recovery after surgery in cases of anti-NMDAR encephalitis with ovarian teratoma emphasizes the need for early recognition of the entity, search for underlying tumor, and tumor removal to improve the prognosis.

Catatonia with Psychosis in an 8-Year-Old Child: A Case Report and a Literature Review

Objective

We present a narrative review of pediatric catatonia and a case report illustrating the complexity of management of psychosis in a child with catatonia.

Method

The literature search used the text terms pediatric, catatonia, and antipsychotics and the search engines PubMed and EBSCO. All references from peer-reviewed journals were reviewed for treatment strategies specific to management in children who are also psychotic. Findings. This 8-year-old girl presented with psychotic symptoms which were initially treated with antipsychotics and evolved into life-threatening catatonia that was eventually stabilized with a total daily dose of 46 mg of lorazepam. Lower doses led to recurrence. Once catatonia improved, she tolerated combined benzodiazepine and antipsychotic treatment. Long-term maintenance over 5 years required maintenance treatment with both benzodiazepines and antipsychotics to prevent relapse.

Conclusions

The extraordinary doses of benzodiazepines found to be optimal for management of catatonia in this child led to improved alertness and orientation, without evident sedation. Catatonia did not recur with later management of psychosis using neuroleptics when added to lorazepam. The current literature on pediatric catatonia does not provide guidance on dose maintenance or when and if to rechallenge with antipsychotics.

CSF studies which ultimately led to the possible diagnosis of anti-NMDAR encephalitis

A 17-year-old man with no significant medical history presented with new-onset seizure activity and altered mental status manifesting as bizarre behaviour, which included rapid pressured and tangential speech, psychomotor agitation, insomnia and delusions. He also had autonomic dysregulation, manifested in labile blood pressures. He had been recently discharged from his first psychiatric hospitalisation. Many studies were performed, including electroencephalogram (EEG), head CT, laboratory work, urine drug screen and lumbar puncture with cerebral spinal fluid studies, which ultimately led to the diagnosis of anti-N-methyl-D-aspartate receptor (NMDAR) autoimmune encephalitis. He was treated with five rounds of plasmapheresis with complete resolution of his altered mental status. This case highlights the importance of being familiar with the presentation of anti-NMDAR autoimmune encephalitis, especially in cases of new-onset mental status changes with psychotic like symptoms, seizure-like activity and autonomic dysregulation as early detection and treatment improves chances of good prognosis with return to baseline cognitive function.

Surgical outcomes in patients with anti-N-methyl D-aspartate receptor encephalitis with ovarian teratoma

BACKGROUND

Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune encephalitis mediated by anti-N-methyl-D-aspartate receptor antibodies. Ovarian teratoma is closely related to anti-N-methyl-D-aspartate receptor encephalitis. However, the optimal treatment remains unknown, and strategies used for the diagnosis and therapy, including surgical intervention of ovarian teratoma, are debatable.

OBJECTIVE

The objective of the study was to study the clinical features of anti-N-methyl-D-aspartate receptor encephalitis with ovarian teratoma to further understand the disease.

STUDY DESIGN

This single-center prospective study included patients with anti-NMDAR encephalitis with ovarian teratoma from 2011 to 2016 who were admitted to Peking Union Medical College Hospital, Beijing, and discussed the clinical characteristics, treatment, and prognosis of the disease. The diagnosis of anti-N-methyl-D-aspartate receptor encephalitis was established preoperatively by identifying anti-N-methyl-D-aspartate receptor antibodies in the cerebrospinal fluid. Ovarian teratomas were suspected preoperatively by pelvic ultrasound and were diagnosed pathologically after laparoscopic detection and ovarian tumor resection. All patients were treated with first-line immunotherapy (steroids, intravenous immunoglobulin, and plasmapheresis), and when the therapy failed, they were treated with second-line immunotherapy (cyclophosphamide and rituximab). All patients were followed up regularly, and N-methyl-D-aspartate receptor antibodies, pelvic ultrasound, and neurological condition were monitored. Neurological symptoms were assessed using the modified Rankin Scale.

RESULTS

A total of 108 female patients with anti-N-methyl-D-aspartate receptor encephalitis were screened, of whom, 29 patients (26.9% of 108; mean age ± SD, 23.14 ± 6.59 years) had pathologically confirmed ovarian teratoma. The incidence of fever, decreased consciousness, arrhythmia, central hypoventilation, ventilator-assisted respiration, and intensive unit care (75.9%, 65.5%, 27.6%, 55.2%, 55.2%, and 58.6%, respectively) were significantly higher in patients with ovarian teratoma than in those without ovarian teratoma. The modified Rankin Scale at the acute onset in those 29 patients was 4.11 ± 1.20, which was also much higher than that in patients without ovarian teratoma (3.58 ± 1.08). Of the 29 patients with ovarian teratoma, 22 (75.9%) underwent laparoscopy during the acute onset of neurological symptoms. The mean diameter of the tumor was 4.61 ± 3.41 cm (SD), and the smallest tumor was only 1 cm in the unilateral ovary. All other cysts, except 4 bilateral cysts (13.8%), were unilateral. Only 1 patient was diagnosed pathologically with immature ovarian teratoma, while others had benign ovarian teratomas. In all, 28 patients (96.5%) had a good outcome (modified Rankin Scale ≤2) and 1 died. In the follow-up visit (mean duration, 37.69 months), the relapse rate of encephalitis in patients with ovarian teratoma undergoing laparoscopic cystectomy was 14.6%, whereas for those without ovarian teratoma, the relapse rate was 33.3%. The removal of ovarian teratoma was associated with reduced risk of relapse.

CONCLUSION

Patients having anti-N-methyl-D-aspartate receptor encephalitis with ovarian teratomas tend to present more severe neurological conditions. The diameter of the tumor in these patients is not very large and could be as small as 1 cm, and thus, careful exploration should be considered during surgery. Most of the ovarian teratomas in patients with anti-N-methyl-D-aspartate receptor encephalitis are mature. Early operative treatment is safe and effective because it is associated with reduced risk of relapse and complete recovery.

New Onset Insomnia in a Pediatric Patient: A Case of Anti-NMDA Receptor Encephalitis

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.