First-episode psychosis in a 15 year-old female with clinical presentation of anti-NMDA receptor encephalitis: a case report and review of the literature

Abstract

BackgroundAnti-NMDA receptor encephalitis is an autoimmune disease that was identified in 2007, and manifests in a stepwise manner with psychiatric, neurological and autonomic symptoms. The disease is caused by autoantibodies against NMDA receptors. It can have a paraneoplastic origin, mainly secondary to ovarian teratomas, but it can also be unrelated to the tumor. This disease can affect both sexes and all ages.Case presentationHere, we present a case of a 15 year-old female adolescent with first-episode psychosis with anti-NMDA receptor encephalitis not related to tumor, which manifested with delusion, hallucinations, panic attacks, agitation, and neurological symptoms, and later with autonomic instability. She was treated with immunotherapy and psychiatric medication resulting in improvement of her main psychiatric and neurological symptoms.ConclusionOur main objective in presenting this case is to alert clinicians to this challenging and recent disease that has a clinical presentation that might resemble a functional psychiatric condition and can be underdiagnosed in the context of child and adolescent psychiatry.

Anti-nmda Receptor Encephalitis In A Young Girl With Altered Behaviour And Abnormal Movements

“…Patients suffering from autoimmune encephalitis usually present with irritability, abnormal movements and other neuropsychiatric symptoms, making it difficult to differentiate them from primary psychiatric patients. 5 This patient had similar presentation, as reported in the few case reports involving the local as well as foreign patients. 5,6 Psychiatric manifestations have been reported among patients suffering from various neurological disorders including dementia, Parkinson disease, encephalitis, multiple sclerosis, epilepsy and many others.…”

“…5 This patient had similar presentation, as reported in the few case reports involving the local as well as foreign patients. 5,6 Psychiatric manifestations have been reported among patients suffering from various neurological disorders including dementia, Parkinson disease, encephalitis, multiple sclerosis, epilepsy and many others. 7 However, in most cases the neurological symptoms appear first or distinct pattern of disease does not allow the psychiatric symptoms to mask the original disease; but in the case of anti-NMDA receptor encephalitis, neurological symptoms are not distinct enough to reach the diagnosis at the early phase of presentation.…”

Occult teratoma in a case of N-methyl-D-aspartate receptor encephalitis

“…6 When a tumor is absent, other immunological mechanisms and genetic predisposition likely play a role. 7,8 NMDARe is diagnosed by detection of immunoglobulin G antibodies against the glutamate NR1 or NR2 subunits of the NMDAR in the serum and/or with a higher sensitivity in the cerebral spinal fluid (CSF). 1 Electroencephalogram (EEG) may demonstrate nonspecific focal slowing, epileptiform activity, and periodic lateralization epileptiform discharges that can be used to exclude non-convulsive seizures.…”

“…1,5 The pathophysiology of NMDARe is not well understood. 7,8 In cases in which the patient has a teratoma, it is thought that the tumor triggers production of antibodies against the NR1 and/or NR2 subunits of the N-methyl-D-aspartate subtype glutamate receptor (NMDAR). 6 When a tumor is absent, other immunological mechanisms and genetic predisposition likely play a role.…”

The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis

“…Many of these people present to mental health services initially, before the autoimmune nature of their illness becomes manifest, with numerous case reports and small case series identifying anti-NMDAR encephalitis in those presenting with an initial diagnosis of psychosis. 3 – 10 Although early detection and initiation of immunotherapy is important to improve their long-term outcome, 11 , 12 presentation to mental health services potentially delays diagnosis and appropriate treatment. In contrast, detection of classical anti-NMDAR encephalitis is rarely described in established schizophrenia and related psychotic disorders.…”