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

Abstract

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.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

“…There are two distinct aspects to treating catatonia: specific treatments for catatonia per se and treatments for the disorder(s) underlying catatonia, where identified. While employing either one of these approaches may be effective in some cases, there are many cases where using either one of these strategies alone fails but using the other or a combination of the two is successful ( Asnis, 2020 ; Bogdan et al, 2022 ; Ekici et al, 2021 ; Johnson et al, 2022 ; Lee and House, 2017 ; Marques Macedo and Gama Marques, 2019 ; Sundaram et al, 2021 ). In addition, consideration must be given to the prevention and management of the medical complications of catatonia.…”

Encephalitis: Diagnostic and Management Challenges

“…Prior to being moved to the medical care unit, many NMDAR encephalitis patients with initial catatonic symptoms first undergo a psychiatric evaluation or are admitted to psychiatric facilities, thus delaying diagnosis and treatment. 10 Serotonin syndrome and neuroleptic malignant syndrome frequently exhibit similar symptoms to autoimmune encephalitis. In contrast, patients with anti-NMDAR encephalitis may initially present with psychosis and be treated with neuroleptics.…”