Agitation Management in Pediatric Males with Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Schumacher, Lauren; Mann, Andrea P.; MacKenzie, James G.

doi:10.1089/cap.2016.0102

Cited by 22 publications

(6 citation statements)

References 26 publications

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“…The reasons for exclusion are presented in Appendix S1. Finally, 22 records (containing the present case) were included 6,21–40 . Only cases where NI was suspected were included from the case series.…”

Section: Resultsmentioning

confidence: 99%

“…Finally, 22 records (containing the present case) were included. 6,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] Only cases where NI was suspected were included from the case series. For the included observational study, the cases reporting signs and symptoms suspicious of those complications were included, and individuals labeled as 5, 7, and 18 of the 21 patients were excluded for having symptoms different from the DSM-5 criteria.…”

Section: Systematic Review and Synthesismentioning

confidence: 99%

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Neuroleptic intolerance in the context of anti‐N‐methyl‐D‐aspartate receptor encephalitis: A systematic review and synthesis of global case reports

Pacheco‐Barrios

Navarro‐Flores²,

Melo

et al. 2022

Acta Neuro Scandinavica

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Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis presents commonly with psychiatric symptoms. One cohort of these patients reported that antipsychotic administration led to neuroleptic intolerance (NI) in 19% of them, which was preventable by a prompt encephalitis diagnosis. To date, there is no clear description of the "neuroleptic intolerance" spectrum in general or during anti-NMDAR encephalitis.We aimed to synthesize epidemiological and clinical characteristics of patients with NI and confirmed anti-NMDAR encephalitis, the time to the encephalitis diagnosis, the disease course, outcomes at discharge, and associated factors. We systematically searched three databases, to include clinical cases, case series, and observational studies. Additionally, we reported one clinical case. Results were summarized using narrative synthesis and the quality of the included studies was assessed. We included 22 records representing 40 patients (28 females; mean age, 24.6). Overall, the evidence quality was low. Initially, most cases were admitted in psychiatric wards (70%) with purely psychiatric symptoms (37.5%). However, most of them developed subtle concomitant neurological symptoms. The mean time to anti-NMDAR encephalitis diagnosis was 26.7 days, which was triggered by the NI in six patients. We found no association between clinical variables as delayed diagnosis, admission to psychiatric wards or the presence of malignancy with outcome variables as unfavorable outcomes at discharge, ICU, or mechanical ventilation requirement. A thorough neurological examination in young patients with new-onset psychiatric symptoms could help emergency physicians, neurologists, and psychiatrists suspect anti-NMDAR encephalitis earlier. Awareness of NI as a potential side effect during suspected or confirmed anti-NMDAR encephalitis is encouraged.

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Section: Resultsmentioning

confidence: 99%

Section: Systematic Review and Synthesismentioning

confidence: 99%

Neuroleptic intolerance in the context of anti‐N‐methyl‐D‐aspartate receptor encephalitis: A systematic review and synthesis of global case reports

Pacheco‐Barrios

Navarro‐Flores²,

Melo

et al. 2022

Acta Neuro Scandinavica

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“…Patients may develop hyperthermia, muscle rigidity, coma or rhabdomyolysis that suggest neuroleptic intolerance, but this symptoms may develop in neurolepticnaive patients with anti-NMDARE making it difficult to distinguish between neuroleptic malignant syndrome and genuine symptoms of the disease (9). Due to its profile, with low D2 binding and high affinity for noradrenergic and histamine type I receptors, quetiapine has been successfully used in the treatment of agitation (common feature of anti-NMDARE) in pediatric patients, being less likely to cause extrapyramidal symptoms or neuroleptic malignant syndrome (32).…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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IntroductionCatatonia 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 ReportHere 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).DiscussionThe 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).ConclusionChild 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.

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“…1,10 We followed international guidelines for immunosuppression and her MRI even improved after the first two weeks, and we transitioned to second-line immunosuppression with rituximab because of persistent coma and the refractory oral dyskinesias, 11 the latter of which eventually required partial lingual excision and mechanical jaw fixation. In retrospect, we should have considered additional multi-modal pharmacological management of the patient's agitation and dyskinesia which have been demonstrated to be useful in managing NMDARE, eg, quetiapine 12 and clonidine. 13 We encountered limitations in our settings.…”

Section: Discussionmentioning

confidence: 99%

Fatal Autoimmune Anti-NMDA-Receptor Encephalitis with Poor Prognostication Score in a Young Kenyan Female

Rakiro¹,

Sokhi²

2021

IMCRJ

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Auto-immune N-methyl-D-aspartate receptor encephalitis (NMDARE) is a relatively recently described cause of acute encephalopathy with very few reports from sub-Saharan Africa (SSA). We report a case of NMDARE in a young Kenyan female who was transferred to our facility with headaches, insomnia, behaviour changes and latterly pathognomonic orofacial dyskinesias. We comprehensively ruled out infectious and other inflammatory/auto-immune causes. She was diagnosed with NMDARE by positive antibody testing in serum and cerebrospinal fluid and changes on brain magnetic resonance imaging. She was immunosuppressed with high-dose steroids, intravenous immunoglobulins, plasma exchange and rituximab, and showed signs of neurological improvement clinically and radiologically. Unfortunately, she succumbed to septic shock from prolonged intensive care. This is the first report of NMDARE in an indigenous patient from the eastern SSA. The majority (>80%) of patients are either left with mild disability or make a full recovery after NMDARE, but some factors -which comprise the NMDARE One-Year Functional Status (NEOS) prognostication score -can adversely affect outcome, as was the case in our patient.

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Agitation Management in Pediatric Males with Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Abstract: These cases and review of the literature suggest that quetiapine may be particularly beneficial for treating agitation secondary to anti-NMDAR encephalitis in pediatric patients and have fewer adverse effects.

Cited by 22 publications

References 26 publications

Neuroleptic intolerance in the context of anti‐N‐methyl‐D‐aspartate receptor encephalitis: A systematic review and synthesis of global case reports

Neuroleptic intolerance in the context of anti‐N‐methyl‐D‐aspartate receptor encephalitis: A systematic review and synthesis of global case reports

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

Fatal Autoimmune Anti-NMDA-Receptor Encephalitis with Poor Prognostication Score in a Young Kenyan Female

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