Poster 327 The Tribulations, Trials, and Triumphs of Treating and Rehabilitating Hemiballismus: A Case Report

Abstract

A 26-year-old woman presenting to acute care hospital with new-onset seizures and was discharged home on Keppra with neurology follow-up. She re-presented to the acute care hospital with psychotic behaviors including agitation, auditory hallucinations, and catatonia. A lumbar puncture demonstrated encephalitis and she received IV steroids and IVIG. She was transferred to a tertiary care center for a whole-body PET scan which was inconclusive for malignancy. The results of a paraneoplastic panel were significant for anti-NMDA receptor antibodies. Ultrasound of the pelvis showed a left ovarian mass. She underwent left oophorectomy with tumor pathology positive for a mature teratoma. Further treatments included total plasma exchange, IVIG, and methylprednisolone IV burst with taper. Patient was transferred to acute rehabilitation on post-operative day three. She was previously independent and at time of transfer to acute inpatient rehabilitation required Min A mobility, Mod I ADLs, and Mod A for cognition. Setting: Tertiary Care Hospital/Acute Inpatient Rehabilitation Hospital. Results: The patient completed a course of acute inpatient rehabilitation and was discharged to home at a supervision level for ADLs, mobility, and cognition. Patient's psychotic behaviors resolved prior to discharge. Discussion: Anti-N-Methyl-D-Aspartate receptor (NMDA-R) encephalitis is a rare autoimmune disorder that results in acute inflammation of the brain. The associated syndrome is frequently characterized in young women with teratomas of the ovary who develop symptoms that resemble acute psychiatric illness/symptoms. Pathophysiology of the syndrome is poorly understood; however, in the case of ovarian teratomas, it is suspected that the tumor releases NMDA-R. NMDA-R antibodies in serum and CSF target the NR1 of the NMDA-R of the tumor and in neural tissue. The receptors suppress the NMDA protein channels/electrical pathways in the brain. Review of literature suggests that tumor resection, immunomodulation, and corticosteroid therapies are associated with improved outcomes. Conclusions: Anti-NMDA-R encephalitis is rare autoimmune disorder. In young women, it is frequently associated with ovarian teratomas. Anti-NMDA-R encephalitis should remain in the differential diagnosis in previously healthy young women with new onset psychiatric symptoms. Level of Evidence: Level VPoster 327