Autoimmune encephalitis with psychosis: Warning signs, step-by-step diagnostics and treatment

Abstract

Objectives: Despite intensive research, schizophrenia and schizoaffective disorders continue to be theoretical constructs that describe clinical syndromes and no pathophysiologically defined diseases. Moreover, there are no clear biomarkers at hand. Therefore, these diagnoses are still set up based on clinical ICD-10/DSM-5 criteria and the exclusion of alcohol-/drug-associated, systemic or other brain organic causes. Methods: Recently, autoimmune encephalitis with psychotic symptoms caused by specific antineuronal antibodies has been identified as a rare, but potentially treatable differential diagnosis. However, these inflammatory brain diseases are not reliably detected by our current routine diagnostic workup in psychiatry. This qualitative review provides structured diagnostic and therapeutic support for clinical practice. Results: Disturbances of consciousness and orientation, catatonia, speech dysfunction, focal neurological signs, epileptic seizures/EEG abnormalities or autonomic dysfunction are warning signs in psychiatric patients which should always induce cerebrospinal fluid analysis with determination of antineuronal autoantibodies. Currently established immunotherapy strategies are summarised, taking into account international expert advice. Conclusions: Guided by clinical warning signs, our qualitative review enables rapid and reliable diagnosis of definite autoimmune encephalitis. This is of high relevance for the affected individuals, since early and sufficiently intense immunotherapy often leads to a good prognosis despite severe illness. ARTICLE HISTORY

Autoimmune encephalitis as a differential diagnosis of schizophreniform psychosis: clinical symptomatology, pathophysiology, diagnostic approach, and therapeutic considerations

“…Fig. 2 Red flags that should lead to antibody diagnostics (according to [2,5,22,36,53,55,61,67,74,76,77,85]). EEG electroencephalography, MRI magnetic resonance imaging All serum-Ab findings should be interpreted in the context of extended history data, the clinical syndrome, and the examination findings (especially including CSF Ab testing; [51,82,85] Compared to MRI, FDG-PET possibly has higher sensitivity for inflammatory changes ( [5,28,35]; Fig.…”

“…The risk for extrapyramidal motor side effects seems to be increased in patients with AEs [49,67,76,77]. Therefore, psychotic symptoms in the context of AP can be symptomatically treated with antipsychotics with a low risk for motor side effects [76,77]. Benzodiazepines can be used for anxiolysis and sedation and, in higher doses, for the treatment of catatonic symptoms [76,77].…”

Autoimmune encephalitis: differences of clinical features between antibody-positive and antibody-negative conditions

“…Considering the potential relationship between antibody status and immune injury, we speculate that the body suffer immune injury might easier to induce the occurrence of other immune diseases, those conditions are existed in antibody-positive AE which was reported by Ohkawa T [22][23], but not in antibody-negative AE, although further investigations are needed. Furthermore, the state of antibodies may reflect the severity of immune damage, as found by others that the antibody level could be reduced as the improvement of symptoms [10].…”

Long-term Outcomes of Patients with Anti–Leucine-Rich Glioma-Inactivated 1 Encephalitis

“…Immunotherapy plays a key role in the treatment of autoimmune epilepsy. 3,5,16,[22][23][24] A study of 29 patients with anti-LGI1 encephalitis by Sarosh et al found that immunotherapies showed a remarkable reduction in FBDS frequency 21 . Among 27 patients receiving immunotherapy, 14 patients (52%) showed a > 50% reduction in seizure frequency.…”