Autoimmune limbic encephalitis presenting as relapsing psychosis

Abstract

A 34-year-old woman with a history of relapsing psychosis presented with a 15-month history of impassivity and social withdrawal associated with cognitive impairment. The subsequent recurrence of psychomotor agitation, auditory hallucinations and delusional thinking resulted in an emergency admission under psychiatric services. Initial investigations, including MRI of the brain and cerebrospinal fluid studies were unremarkable and she was treated for a primary psychiatric disorder. The diagnosis of autoimmune limbic encephalitis was established after further investigations revealed the presence of antibodies to the NR1 subunit of theN-Methyl-d-aspartate receptor (NMDAR). Immunotherapy resulted in rapid resolution of psychosis and marked improvement in cognitive and social function. This case underlines the importance of considering anti-NMDAR encephalitis within the differential diagnosis of psychosis associated with cognitive impairment even in those with an apparent previous psychiatric history and response to antipsychotics.

Frequency and temporal sequence of clinical features in adults with anti-NMDA receptor encephalitis presenting with psychiatric symptoms

“…Following a course of bilateral ECT treatments, he recovered sufficiently to be discharged, and when the diagnosis was made retrospectively 2 years later he was doing well (Braakman et al ., 2010). Other reports included in the present analysis describe patients who probably had relapsing anti-NMDAr encephalitis over years that were misdiagnosed as recurring psychotic episodes (Hopkins et al ., 2013; Heekin et al ., 2015; Huang et al ., 2015; Yoshimura et al ., 2015). In one of these cases (Heekin et al ., 2015), a 24-year-old woman presented with symptoms consistent with psychotic mania preceded for 6 months by complaints of upper extremity weakness and parasthesias.…”

Olanzapine and Lorazepam Used in the Symptomatic Management of Excited Catatonia Secondary to Anti-N-Methyl-D-Aspartate Receptor Encephalitis

“…Accounts of spontaneous remission without immunotherapy have traditionally been understood as infrequent, with recovery generally taking many months to years [12][13][14]. However, more recent literature suggests that there is a relapsing-remitting form that may be under-recognized [15]. Episodes of relapse and remission have been reported both in cases of anti-NMDA receptor encephalitis where immunotherapy was and was not utilized in treatment [15].…”

“…However, more recent literature suggests that there is a relapsing-remitting form that may be under-recognized [15]. Episodes of relapse and remission have been reported both in cases of anti-NMDA receptor encephalitis where immunotherapy was and was not utilized in treatment [15]. Thus, the possible relapsing-remitting nature of the disease is an important aspect to consider when managing patients with anti-NMDA receptor encephalitis.…”

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Detailed Review of the Different Psychiatric Presentations and Red Flags to Look for in Suspected Cases

“…The patient's psychotic episode resolved, and the associated cognitive and mood impairment improved after immunotherapy. The takeaway message from this case is that it is crucial to consider anti-NMDAR encephalitis in the list of differentials in cases where psychosis is associated with cognitive impairment, even in the light of a previous psychiatric diagnosis [39]. Approximately one in eight adults with anti-NMDAR encephalitis who have been inappropriately admitted to the psychiatric unit turns out to have had prior psychiatric episodes that were most likely caused by anti-NMDAR encephalitis [26].…”

“…Thus, it is important to keep this in mind as a differential diagnosis when assessing patients with a history of previous psychosis who now have features suggestive of systemic or limbic involvement. The true prevalence of anti-NMDAR encephalitis may be underestimated because of how cases can sometimes go unrecognized [39].…”