Acute psychosis in a pregnant patient with Graves’ hyperthyroidism and anti-NMDA receptor encephalitis

Abstract

A previously healthy 36-year-old woman presented with visual hallucinations and acute psychosis manifested predominantly as hypersexuality. Laboratory testing demonstrated elevated free thyroxine levels, suppressed thyroid-stimulating hormone levels and presence of thyroid-stimulating immunoglobulin andthyroid peroxidase (TPO) antibodiesconsistent with Graves’ disease. Despite achieving biochemical euthyroidism, she remained profoundly hypersexual. She did not respond to additional treatment with antipsychotics and corticosteroids, prompting further evaluation. Cerebrospinal fluid analysis detected pleocytosis, elevated IgG, and presence of antibodies against anti-N-methyl-D-aspartate receptor (NMDAR), glutamic acid decarboxylase 65 and TPO. These results suggested a diagnosis of anti-NMDAR encephalitis. Prior to initiation of immunomodulator therapy, she was discovered to be pregnant with date of conception around the time of her original presentation. She received plasmapheresis with resolution of psychosis and decrease in free thyroxine levels. Graves’ disease remitted during the remainder of the pregnancy but relapsed 5 months post partum. She has not had further neuropsychiatric symptoms.

Anti–NMDAR encephalitis complicating pregnancy

“…Among the 14 previously described cases of anti-NMDAR encephalitis complicating pregnancy (table 1),2–13 nine healthy infants were delivered with no neurological sequelae. Two fetuses were miscarried and one fetus was aborted.…”

Anti‐NMDA‐receptor encephalitis during pregnancy: A case report and literature review

“…Pathological examination of tissue sections positive for anti‐NMDA‐R encephalitis highlight the role of teratomas in this disease. According to the case series to date, four of the 12 cases had ovarian teratoma, and the tumors were always explored by MRI 3 weeks to 4 months after the appearance of neurological symptoms (Table ) . Negative results are related to barrier of the gravid uterus, short follow‐up time, or poor auxiliary examination.…”

Postpartum Anti-N-methyl-D-aspartate Receptor Encephalitis: A Case Report and Literature Review

“…With regard to the relationship between anti-NMDAR encephalitis and pregnancy/delivery, 10 patients developed anti-NMDAR encephalitis during pregnancy (6-15), and 5 patients developed the disease during the postpartum period (16-19). One of the major immunological modifications during pregnancy is the Th1/Th2 shift, due to the progressive increases in levels of progesterone and estrogen during pregnancy, which suppress Th1 cytokines and stimulate Th2-mediated immunological responses as well as antibody production (22).…”