Finding the Cause of Psychosis: A Challenging Case of Anti-NMDAR Encephalitis

Abstract

An autoimmune response causing inflammation in the brain tissue is called autoimmune encephalitis. Autoantibodies directed against N-methyl-D-aspartate (NMDA) receptors cause a type of autoimmune encephalitis resulting in memory loss, confusion, and psychosis. A 28-year-old male with a history of schizophrenia, seizure disorder, and stroke presented with a 2-day history of bizarre behavior, restlessness, insomnia, agitation, and hallucinations. He was initially managed for acute psychosis without any improvement. Further workup for organic causes revealed positive NMDAR antibodies in both the cerebrospinal fluid and serum, confirming a diagnosis of autoimmune encephalitis. His condition later improved with steroids and intravenous immunoglobulins. This case signifies the importance of ruling out organic causes in patients with unexplained neuropsychiatric symptoms. NMDA encephalitis is more common in young females with underlying malignancies, especially ovarian teratomas. This case is unique, given the extremely rare occurrence of NMDA encephalitis in male patients without any malignancies.

Brain anomalies in early psychosis: From secondary to primary psychosis

“…This was found to be the case: (i) in autoimmune or inflammatory diseases, as reported in the many cases of anti-NMDAR encephalitis, requiring immunosuppressive therapy and surgery of ovarian teratomas (Sabbula et al 2020;Lwanga et al 2018), or in multiple sclerosis and neurolupus, where psychosis also remitted after immunosuppressive therapy (Jghaimi, Kabbaj, and Essaadouni 2009;Jongen 2006); (ii) in tumoral processes where surgical resection led to full remission in the case of an epidermoid cyst in the pineal gland or a hypothalamic hamartoma (Jiang et al 2018;Al-Hail et al 2010), or clear improvement in a grade II meningioma (Gama Marques 2020), and in morphologic anomalies like arachnoid cysts, where the treatment of the subsequent intracranial pressure could also bring full recovery; finally, (iii) in metabolic disorders such as 5,10-methylenetetrahydrofolate reductase deficiency or Niemann-Pick type C, where adequate supplementation achieved full recovery (Iida et al 2017;Walterfang 2006).…”

“…MRI anomalies are known to be nonspecific and present only in 40 % of patients with anti-NMDAR encephalitis (Pollak et al 2020). But some reports of early secondary psychosis described inflammatory lesions in the left precentral and anterior cingulate gyri, the medial temporal lobes and bilateral insular cortices, or in fronto-parietal and bi-occipital gyri (Söylemez et al 2015;Sabbula et al 2020;Le Foll and Pelletier 2010). Diffuse white matter lesions have also been described in settings where isolated psychotic symptoms revealed the onset of neurolupus (Jghaimi, Kabbaj, and Essaadouni 2009) or of demyelinating disorders such as multiple sclerosis (Jongen 2006) and acute disseminated encephalomyelitis (Neeki et al 2016).…”

Agitation in schizophrenia: origins and evidence-based treatment

“…Agitation in a person previously diagnosed with schizophrenia but now not responding to antipsychotics requires a thorough work-up. A case report of a 28-year-old male with anti-N-Methyl-D-aspartate (NMDA) receptor encephalitis illustrates this point [20 ▪ ]. The presence of agitation as part of catatonia in patients with anti-NMDA receptor encephalitis is further described in a series of 58 patients from the Institute of Neurology and Neurosurgery of Mexico [21].…”