Case report: meningitis as a presenting feature of anti-NMDA receptor encephalitis

Abstract Background Meningitis is a very rare atypical presenting feature of anti-NMDA receptor encephalitis. In our case report, we describe an unusual clinical presentation of anti-NMDA receptor encephalitis with a biphasic pattern of meningitis followed by encephalitis and discuss potential mechanisms underlying this presentation. We aim to widen the differential diagnosis to be considered in a patient presenting with clinical meningitis and pyrexia. Case presentation This is a case of a 33-year old Caucasian woman who initially presented with a lymphocytic meningitis attributed to a viral infection. She subsequently developed fluctuating consciousness, agitation, visual hallucinations, dyskinetic movements, a generalized tonic-clonic seizure, and autonomic instability. Investigations revealed a diagnosis of anti-NMDA receptor encephalitis secondary to a previously unidentified ovarian teratoma. She made an excellent recovery with immunotherapy and removal of the teratoma. Conclusion Clinicians should consider autoimmune encephalitides in individuals with meningitis, particularly where extensive investigations fail to identify a causative pathogen and there is rapid development of an encephalitic phenotype.

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Management And Psychiatric Manifestations Of Anti-NMDA Receptor Encephalitis, A Case Report

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1946 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S525-S526

Author(s):

R. Gallego ◽

A. Flores

Keyword(s):

Case Report ◽

Nmda Receptor ◽

Psychiatric Symptoms ◽

Multidisciplinary Treatment ◽

Autoimmune Disorder ◽

Clonic Seizure ◽

Nmda Receptor Encephalitis ◽

Abnormal Movements ◽

Nmdar Encephalitis ◽

Psychiatric Manifestations

IntroductionAnti-NMDA receptor (NMDAR) encephalitis, formally recognized in 2007 by Dalmau et al, is an autoimmune disorder with a complex presentation that includes psychiatric symptoms, memory deficits, and autonomic instability. The exact incidence is unknown but age, gender, and ethnicity may all play a role. Presence of antibodies against the GluN1 subunit of the NMDAR in the CSF and serum confirm the diagnosis of NMDAR encephalitis.Case reportWe report the case of a previously healthy, 19-year-old woman, 6 weeks pregnant. She had a generalized tonic-clonic seizure followed by psychiatric symptoms, including insomnia, emotional lability, delusions, and disorganized behavior. During the course of the disease, she demonstrated speech impairments and catatonic features associated with abnormal movements.She was provided lorazepam 1 mg twice a day to treat her catatonic symptoms, her insomnia and her speech improved. Olanzapine was introduced, reaching a dose of 20 mg/day for managing psychosis and agitation.DiscussionNMDA-R encephalitis is a novel disorder with prominent psychiatric manifestations that is widely underdiagnosed. Neuroleptics may be helpful for managing psychosis and agitation, but may exacerbate movement abnormalities. Benzodiazepines are helpful for agitation, insomnia and catatonia associated with this condition.ConclusionEarlier recognition of this illness is crucial as prompt diagnosis and multidisciplinary treatment, can potentially improve prognosis. There is an increasing need for psychiatrists to become aware of the disorder and consider it in their differential diagnosis, specially in patients with new onset psychosis, history of encephalitis or subtle neurological symptoms. Careful selection of psychopharmacological interventions may reduce suffering.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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A refractory anti-NMDA receptor encephalitis successfully treated by bilateral salpingo-oophorectomy and intrathecal injection of methotrexate and dexamethasone: a case report

Journal of International Medical Research ◽

10.1177/0300060520925666 ◽

2020 ◽

Vol 48 (10) ◽

pp. 030006052092566 ◽

Cited By ~ 1

Author(s):

Dongmei Wang ◽

Yongming Wu ◽

Zhong Ji ◽

Shengnan Wang ◽

Yunqi Xu ◽

...

Keyword(s):

Nmda Receptor ◽

Intrathecal Injection ◽

Young Female ◽

Good Prognosis ◽

Ovarian Teratoma ◽

Intravenous Methylprednisolone ◽

Intravenous Cyclophosphamide ◽

Case Presentation ◽

Nmda Receptor Encephalitis ◽

Intravenous Methylprednisolone Pulse

Introduction Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is an autoimmune-mediated disease that is common in young female patients with ovarian teratomas. With appropriate immunotherapy, most patients achieve a good prognosis. Nevertheless, some patients may be refractory to first- and second-line immunotherapy, thus alternative treatments are required for these patients. Case presentation: We present a case of anti-NMDA receptor encephalitis with ovarian teratoma. After the prompt removal of the teratoma and intense immunotherapy was administered, including an intravenous methylprednisolone pulse, intravenous immunoglobin, plasmapheresis, immunoadsorption, intravenous cyclophosphamide, and rituximab, the patient’s neurologic status did not improve. Bilateral salpingo-oophorectomy was then conducted, and intrathecal injection of methotrexate (MTX) and dexamethasone (DXM) was performed. The patient’s neurological symptoms improved dramatically, and she achieved a good prognosis after 23 months. Conclusions Intrathecal injection of MTX and DXM may be beneficial for treatment of refractory cases of anti-NMDA receptor encephalitis. Additional research is required to elucidate the mechanisms of intrathecal treatment with this therapy.

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A Case Report: 38-Year-Old Female With Anti-NMDA-Receptor Encephalitis Without Ovarian Teratoma or Occult Malignancy

CHEST Journal ◽

10.1378/chest.1701631 ◽

2013 ◽

Vol 144 (4) ◽

pp. 920A

Author(s):

Olena Lineberry ◽

Amol Patil ◽

Kristina Bailley

Keyword(s):

Case Report ◽

Nmda Receptor ◽

Ovarian Teratoma ◽

Nmda Receptor Encephalitis ◽

Occult Malignancy

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Anti-NMDA Receptor Encephalitis Associated With an Ovarian Teratoma Presenting as First-episode Psychosis: A Case Report

Journal of Psychiatric Practice ◽

10.1097/pra.0000000000000598 ◽

2022 ◽

Vol 28 (1) ◽

pp. 84-88

Author(s):

Pedro Câmara-Pestana ◽

Andreia D. Magalhães ◽

Tiago Mendes ◽

Pedro Levy ◽

Ricardo Coentre

Keyword(s):

Case Report ◽

Nmda Receptor ◽

First Episode Psychosis ◽

Ovarian Teratoma ◽

First Episode ◽

Nmda Receptor Encephalitis ◽

Episode Psychosis

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Anti-NMDA receptor encephalitis in a patient with ovarian teratoma – case report

Postępy Psychiatrii i Neurologii ◽

10.5114/ppn.2017.71277 ◽

2017 ◽

Vol 26 (4) ◽

pp. 246-254

Author(s):

Anna Jasińska-Mikołajczyk ◽

Przemysław Osip ◽

Agnieszka Osip-Permoda ◽

Filip Rybakowski

Keyword(s):

Case Report ◽

Nmda Receptor ◽

Ovarian Teratoma ◽

Nmda Receptor Encephalitis

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Anti-NMDA-Receptor Encephalitis in a Patient with Ovarian Teratoma, Harboring Brain Histology of Varying Developmental Stages and Regions with Chronic Inflammation

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqab191.170 ◽

2021 ◽

Vol 156 (Supplement_1) ◽

pp. S80-S81

Author(s):

S Fatemi ◽

E Qu ◽

J Fullmer

Keyword(s):

Case Report ◽

Nmda Receptor ◽

Developmental Stages ◽

Clinical Symptoms ◽

Cystic Teratoma ◽

Imaging Study ◽

Ovarian Teratoma ◽

Laboratory Findings ◽

Nmda Receptor Encephalitis ◽

Nmdar Encephalitis

Abstract Introduction/Objective Anti-NMDA-receptor encephalitis is a subacute, autoimmune disorder thought to be caused by autoantibodies directed against the N-methyl-D-aspartate (NMDA) receptor. Clinical symptoms of anti-NMDAR encephalitis may mimic schizophrenia and psychotic spectrum disorders or substance-induced psychosis. Although initially described in association with ovarian teratomas in women, anti-NMDAR encephalitis has been reported in individuals without paraneoplastic association, as well as in males. Herein, we report a case of a 29-year-old woman with suicidal ideation and other neuropsychiatric manifestations who was found to have a right ovarian cystic mass by imaging study. Microscopically, the resected ovarian mass is composed of mature skin, fat, cartilage and neural tissues. Nerve, ganglions and multiple brain tissues are present. Cerebellum including external granular cell layer (normally only seen in infants), cerebrum-like, choroid plexus and other neural elements are present. There is peripheral lymphoplasmacytic infiltrates around and within the neuroglial matrix. Cerebral spinal fluid was concurrently tested positive for Anti-NMDAR. The combined clinical, histological, and laboratory findings confirmed the above diagnosis. Although Anti-NMDAR encephalitis is a familiar entity to many clinical psychiatrist and neurologists, it is less commonly reported in the pathology literature. Its resultant relationship to cystic teratoma warrants awareness of this condition by pathologists. Methods/Case Report Case Report Results (if a Case Study enter NA) NA Conclusion Anti-NMDA-receptor encephalitis is related to cystic teratoma, therefore pathologists need to be aware of this condition.

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