Pediatric anti-NMDA receptor encephalitis with catatonia: treatment with electroconvulsive therapy

Electroconvulsive therapy in N-methyl-d-aspartate receptor encephalitis: A retrospective cohort and scoping review of literature

Neuropsychiatric symptoms in N-methyl-d-aspartate receptor encephalitis (NMDARE) have led some to pursue empiric trials of electroconvulsive therapy (ECT). A scoping review identified 39 patients diagnosed with NMDARE undergoing ECT. Separately, a retrospective cohort was reviewed to characterize 21 patients. Clinical improvement was attributed to ECT in 49% of patients in the scoping review and 19% of patients in the retrospective cohort; timing of immunotherapies was a confounding factor. Worsening of clinical course following ECT was reported in 28% of patients in the scoping review and 38% of patient in the retrospective review. There is currently insufficient data supporting a beneficial effect of ECT in NMDARE.

Analysis of characteristics of movement disorders in patients with anti-N-methyl-D-aspartate receptor encephalitis

Objective

Movement disorders (MDs) are common in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis but are poorly studied. This study aimed to investigate the clinical characteristics of MDs and the clinical differences between patients with and without MDs in anti-NMDAR encephalitis.

Methods

A retrospective study was conducted on patients with anti-NMDAR encephalitis who were first diagnosed and treated in the First People's Hospital of Yunnan Province from January 2017 to September 2022. According to the presence or absence of MDs, all patients were divided into two groups, and the clinical manifestations, auxiliary examinations, and prognosis of the two groups were compared. Patients in the MDs group were further subgrouped by different ages (<12 years, 12-17 years, and ≥ 18 years) and genders, and the prevalence of each MD was compared in different age and gender groups.

Results

(1) In our study there were 64 patients, of whom 76.6% (49/64) presented with MDs; the median age of onset in patients with MDs was 21 (15,35) years and 65.3% (32/49) were female. The three most common MDs were orofacial dyskinesia (OFLD) (67.3%), dystonia (55.1%), and stereotypies (34.7%). Patients <12 years were more likely to experience chorea than patients in other age groups (p = 0.003). (2) Compared with the non-MDs group, patients in the MDs group showed higher rates of prodromal manifestations, autonomic dysfunction, consciousness disorders, as well as pulmonary infection and gastrointestinal dysfunction (all p < 0.05). Peripheral blood neutrophil to lymphocyte ratio (NLR) (p = 0.014), the proportion of cerebrospinal fluid (CSF) NMDAR antibody titers ≥1:32 (p = 0.047), ICU admission rate (p = 0.04), length of stay (p = 0.007), maximum mRS score in the course of disease (p = 0.001) and mRS score at discharge (p = 0.006) in the MDs group were significantly higher than the non-MDs group.

Conclusion

MDs associated with anti-NMDAR encephalitis were predominantly hyperkinetic. Chorea occurred more commonly in patients aged <12 years. Patients with MDs were prone to autonomic dysfunction, consciousness disorders, pulmonary infection, and gastrointestinal dysfunction; they had more intense inflammation, more severe disease, and a poorer short-term prognosis.

Electroconvulsive therapy for catatonia in anti-NMDA receptor encephalitis: A case series

BACKGROUND

Anti-NMDAR encephalitis is the most common cause of immune-mediated catatonia.

CASE SERIES

Three females presented with neuropsychiatric symptoms and were empirically treated with first-line immunotherapy and ovarian teratoma resection for suspected autoimmune encephalitis, preceding diagnostic confirmation via NMDAR antibody positivity. They required escalating large doses of benzodiazepines for refractory malignant catatonia resulting in ICU level care. ECT treatments were initiated, and patients were gradually noted to have clinical improvement as was measured by the Bush-Francis Catatonia Rating Scale.

CONCLUSIONS

Clinicians should recognize catatonia among patients with suspected anti-NMDAR encephalitis and consider the early implementation of ECT into treatment algorithms.

Adolescents and Young Adults With Anti-N-methyl-D-aspartate Receptor Encephalitis With Excited Catatonia: Literature Review and 2 Illustrative Cases

BACKGROUND

Catatonia is a complex neuropsychiatric syndrome that can be associated with several underlying etiologies including primary psychiatric and autoimmune disorders. Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune disorder typically characterized by seizures, movement abnormalities, and behavioral changes. Anti-N-methyl-D-aspartate can present with complex neuropsychiatric symptoms including catatonia which can be challenging for clinicians to identify as excited catatonia can mimic delirium and psychiatric disorders such as psychosis and mania.

OBJECTIVES

To identify and present cases of anti-N-methyl-D-aspartate receptor encephalitis where excited catatonia is the presenting symptom.

METHODS

We present 2 case studies of agitation and disinhibition in an adolescent and young adult that were ultimately found to be secondary to autoimmune receptor encephalitis, in both cases, confirmed by cerebrospinal fluid analysis to be due to anti-N-methyl-D-aspartate receptor antibodies.

RESULTS

Excited catatonia was suspected and initially treated with immunological therapy and high doses of lorazepam. As the severity of catatonia progressed with limited improvement with lorazepam, both cases were ultimately effectively treated with electroconvulsive therapy.

CONCLUSIONS

Excited catatonia should be considered with presentations of bizarre behavior, agitation, disinhibition, and other psychotic symptoms in patients with no prior psychiatric history. Although the primary treatment for catatonia associated with anti-N-methyl-D-aspartate receptor encephalitis is immunomodulatory therapy paired with benzodiazepines, electroconvulsive therapy has been shown to be an effective and safe adjuvant treatment that is especially useful for management of excited catatonia.

Molecular and cellular mechanisms leading to catatonia: an integrative approach from clinical and preclinical evidence

This review aims to describe the clinical spectrum of catatonia, in order to carefully assess the involvement of astrocytes, neurons, oligodendrocytes, and microglia, and articulate the available preclinical and clinical evidence to achieve a translational understanding of the cellular and molecular mechanisms behind this disorder. Catatonia is highly common in psychiatric and acutely ill patients, with prevalence ranging from 7.6% to 38%. It is usually present in different psychiatric conditions such as mood and psychotic disorders; it is also a consequence of folate deficiency, autoimmunity, paraneoplastic disorders, and even autistic spectrum disorders. Few therapeutic options are available due to its complexity and poorly understood physiopathology. We briefly revisit the traditional treatments used in catatonia, such as antipsychotics, electroconvulsive therapy, and benzodiazepines, before assessing novel therapeutics which aim to modulate molecular pathways through different mechanisms, including NMDA antagonism and its allosteric modulation, and anti-inflammatory drugs to modulate microglia reaction and mitigate oxidative stress, such as lithium, vitamin B12, and NMDAr positive allosteric modulators.

Teenager with acute psychosis due to non-paraneoplastic anti-N-methyl-d-aspartate receptor encephalitis with a successful recovery: A case report

Introduction

Anti NMDAR encephalitis is a neuropsychiatric syndromic disease caused by an immunological response. Acute behavioral changes, psychosis, and catatonia are common clinical manifestations, are seizures, amnesia, speech difficulties, dyskinesia, and autonomic dysregulation.

Case presentation

We discuss the case of a 14-year-old girl who had psychotic symptoms and tested positive for anti-NMDAR antibodies.

Discussion

Patients present with psychiatric symptoms such as delusions, hallucinations, agitation, changes in speech mania, disorganized thinking, catatonia, insomnia, and often seizures. Anti-NMDAR encephalitis should be suspected in teenage patient with acute psychotic symptoms and seizure episodes. A multidisciplinary treatment strategy is required.

Conclusion

The delayed treatment can lead to complications and delayed recovery complicating the disease process so multidisciplinary approach of treatment is necessary.

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Acute psychotic symptoms with seizure episodes in adolescent patient should have a suspicion of anti-NMDAR encephalitis.

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The delayed treatment can lead to complications and delayed recovery complicating the disease process.

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Multidisciplinary approach of treatment is necessary.

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.

Case Report: Anti-NMDAR Encephalitis Presenting With Catatonic Symptoms in an Adolescent Female Patient With a History of Traumatic Exposure

INTRODUCTION

Catatonia is a severe syndrome associated with a high proportion of underlying organic conditions including autoimmune encephalitis. The link between catatonia and psychiatric conditions such as mood disorders and schizophrenia spectrum disorders is well established while the causative effect of Post-Traumatic Stress Disorders and stress related disorders remains speculative.

CASE REPORT

Here we describe the clinical case of a 14-year-old female patient presenting to the Emergency Department of a Pediatric University Hospital with acute changes in behavior five days after a sexual abuse. Acute stress reaction was suspected. Afterwards she developed catatonic symptoms alternating from stupor to excitement, resistant to the usual treatment with benzodiazepines. The first line examinations (PE, MRI, EEG) were inconclusive. The final diagnosis of anti-NMDARE was made 22 days after her admission in a University Department of Child and Adolescent Psychiatry. Her state improved after first- and second-line immunotherapy, with no signs of relapse at this day (8 months of clinical follow-up).

DISCUSSION

The diagnosis of anti-NMDARE is challenging, involving a multidisciplinary approach. The neuropsychiatric features are complex, with no specific psychiatric phenotype. Several hypotheses are discussed to determine the role of an acute environmental stressors in the emergence of such complex neuropsychiatric clinical presentation (i.e., shared vulnerability, precipitators, consequences of preexisting psychiatric symptoms).

CONCLUSION

Child and adolescent psychiatrists and pediatricians should be aware of the overlap between neurological and psychiatric features in the setting of anti-NMDARE. Catatonia should not be dismissed as a primary psychiatric disorder even in the context of recent traumatic exposure.

Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines

ABSTRACT

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.

The Effectiveness of Electroconvulsive Therapy on Catatonia in a Case of Anti-N-Methyl-D-Aspartate (Anti-NMDA) Receptor Encephalitis

Catatonia is a symptom seen in a variety of neuropsychiatric conditions, including anti-N-Methyl D-aspartate receptor (NMDAR) encephalitis. When associated with anti-NMDAR encephalitis, catatonia is resistant to standard therapy. However, electroconvulsive therapy (ECT) has shown promising success in management. This case report presents a 25-year-old African American female who presented to the emergency room with nervousness, sweating, insomnia, and visual and auditory hallucinations. She was treated symptomatically for anxiety but returned to the hospital after she continued to experience worsening symptoms. Her anxiety worsened, and she became more agitated, warranting an extensive workup, including magnetic resonance imaging (MRI) and electroencephalogram (EEG), which showed normal findings. She also had an anti-NMDA receptor antibodies titer done, which showed a positive titer result. She was treated with intravenous steroids, intravenous immunoglobulin G (IgG), plasma exchange, and rituximab, which did not improve her symptoms, and she was discharged home after a prolonged hospital stay. On follow-up visits, she reported worsening confusion, aggression, and suicidal behaviors. The patient was readmitted, during which she experienced catatonia and psychiatric symptoms, and her anti-NMDAR titer had increased to 1:1280. Further treatments with intravenous steroids, intravenous IgG, plasma exchange, and rituximab, including haloperidol and clonazepam, failed to improve her condition. However, her condition improved remarkably following treatment with 12 rounds of ECT. No randomized control trial has been done to demonstrate the effectiveness of ECT in the treatment of anti-NMDAR encephalitis despite various reports of the effectiveness of this treatment modality. This case report adds to the growing clinical evidence in support of the use of ECT in anti-NMDAR encephalitis patients with catatonia. ECT can be incorporated as standard protocol in the treatment of catatonia and associated psychiatric symptoms when managing a patient with anti-NMDAR encephalitis associated with catatonic features.

Catatonia secondary to anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis: a review

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.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

Anti-N-methyl-D-aspartate receptor encephalitis: A review of pathogenic mechanisms, treatment, prognosis

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatable autoimmune disorder characterized by prominent neuropsychiatric symptoms that predominantly affects children and young adults. In this review, we discuss the pathogenic mechanisms and immunologic triggers of anti-NMDAR encephalitis, and provide an overview of treatment and prognosis of this disorder, with specific focus on the management of common symptoms, complications, and patients during pregnancy. Most patients respond well to first-line treatment and surgical resection of tumors. When first-line immunotherapy fails, second-line immunotherapy can often improve outcomes. In addition, treatment with immunomodulators and tumor resection are effective treatment strategies for pregnant patients. Benzodiazepines are the preferred treatment for patients with catatonia, and electroconvulsive therapy (ECT) may be considered when pharmacological treatment is ineffective. Age, antibody titer, cerebellar atrophy, levels of biomarkers such as C-X-C motif chemokine 13 (CXCL13), cell-free mitochondrial (mt)DNA in cerebral serum fluid (CSF), and timing from symptom onset to treatment are the main prognostic factors. Patients without tumors or those who receive insufficient immunotherapy during the first episode are more likely to relapse.