A patient with a long history of relapsing psychosis and mania presenting with anti-NMDA receptor encephalitis ten years after first episode

Abstract

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a recently discovered autoimmune disorder, in which antibodies target NMDARs in the brain, leading to their removal from synapses. Early in the disease course, patients often present with marked psychosis and mood disturbances (i.e. mania, depression), explaining why most of these patients are first seen by psychiatrists. Hence, autoimmune encephalitis is receiving growing attention from psychiatry, mainly owing to concerns over misdiagnosing immunomediated and potentially curable disorders as primary psychiatric disorders, such as schizophrenia or major depressive disorder. Although anti-NMDAR encephalitis occurs in the context of new-onset psychiatric symptoms, there is a lack of information on differential diagnosis and treatment of this disorder after a long-term diagnostic history of functional psychiatric disorders. We report a case of a patient with a long history of bipolar affective disorder evolving with anti-NMDAR encephalitis, initially misdiagnosed as non-organic psychosis.

Steroid-responsive Encephalopathy as a Semblance of Neuroleptic Malignant Syndrome in a Patient with Schizophrenia

“…Although CSF, EEG, and neuroimaging profile were not conclusive for an autoimmune encephalitis, which may occur due to a range of factors, [8][9][10] the presence of cerebral small-vessel disease too suggested a primary immune-based vasculitis and encephalitis. The presentation in the index patient remarkably differed from the previously reported cases which had a younger age of onset of illness, [2][3][4][5][6] had a female predominance, [2,3,5,6] and had a seizure or other neurological symptoms at the initial presentation. [2,3,6] The nonevaluation of a panel of other autoantibodies was a limitation in this case, and a definitive diagnosis based on a brain biopsy was not feasible.…”

“…The presentation in the index patient remarkably differed from the previously reported cases which had a younger age of onset of illness, [2][3][4][5][6] had a female predominance, [2,3,5,6] and had a seizure or other neurological symptoms at the initial presentation. [2,3,6] The nonevaluation of a panel of other autoantibodies was a limitation in this case, and a definitive diagnosis based on a brain biopsy was not feasible. The future course of management for this patient would be a course of cyclophosphamide with/without rituximab, evaluation of cognition and executive functions with standard tools, and rehabilitation.…”

Síntomas neuropsiquiátricos en encefalitis por anticuerpos contra el receptor N-metil-D-aspartato: a propósito de dos casos

“…Debido a que los síntomas psiquiátricos se presentan en etapas tempranas de la enfermedad, aproximadamente el 70% de los pacientes son evaluados inicialmente por un psiquiatra. Peor aún, existen escasos casos de encefalitis anti-NMDAR donde los síntomas psiquiátricos se presentan por largos periodos antes de la aparición de síntomas neurológicos, como el caso reportado por Simabukuro y col. (9) de un paciente con larga historia de desorden bipolar que presentó luego de 10 años un episodio psicótico seguido de discinesias orofaciales asociadas a alza térmica. Y los casos, donde los sín-tomas psiquiátricos son la única expresión, recientemente llaman la atención, pues existe una clara relación entre esquizofrenia y trastornos de la autoinmunidad.…”

Increased serum levels of NMDA receptor antibodies in female patients with bipolar disorder

“…Furthermore, manic patients' serum NMDA-NR2 antibody levels decreased at the six-month follow-up; which implies an association between antibody levels and the manic state. Previous data from case reports (75)(76)(77)(78) and case-control studies (36,38,79) suggest a possible relationship with NMDA-R antibody seropositivity and manic or depressive mood episodes. Despite focusing exclusively on euthymic patients, our results revealed significantly higher NMDA-R antibodies in patients with BD.…”