Sore eyes and psychosis

Abstract

We present the case of a 30-year-old woman who presented with sexual disinhibition and altered behaviour following an episode of optic neuritis. Her only history was of anxiety disorder. Her differential diagnosis was neurological versus psychiatric. Routine blood tests were unremarkable at this stage. MRI revealed non-specific change and lumbar puncture revealed a slight lymphocytosis and elevated protein and glucose in the cerebrospinal fluid (CSF). PCR on the CSF was negative for viruses: Adenovirus, varicella zoster virus, herpes simplex virus, enterovirus and parechovirus. She was initially treated with intravenous acyclovir to little effect. Antipsychotics olanzapine and haloperidol were also trialled and continued for 3 weeks in total. Once again these medications failed to affect the patient's behaviour but she did begin to show the side effects associated with these medications. Further test results became available at this point-she was anti-N-methyl D-aspartate (NMDA) receptor antibody positive. A diagnosis of anti-NMDA receptor antibody encephalitis was made. The patient was started on cyclophosphamide and methylprednisolone to good effect.

Optic Neuropathy As the Initial Presenting Sign of N-methyl-d-aspartate (NMDA) Encephalitis

“…To our knowledge, there have been three reported cases of patients with NMDA encephalitis with a concomitant optic neuritis. [3][4][5][6] In two of these cases, the visual loss was the presenting symptom. 4,6 The key findings surrounding their presentation are listed in Table 1.…”

Optic Nerve Atrophy in N-methyl-D-aspartate (NMDA) Encephalitis

“…1,2 The link between NMDA receptor encephalitis and optic neuropathy has not been widely reported and remains preliminary, but it is possible these two are part of the same autoimmune syndrome. 5 The goal of this case report is to provide additional evidence for the possible link between these two entities and to demonstrate changes seen on neuroimaging. The progressive atrophy on MRI of the anterior visual pathway has not previously been reported.…”

“…1 Tumours, especially teratomas, are frequently associated with NMDA encephalitis; however, only 5% of male patients older than 18 years have been found to have an underlying tumour. Optic neuropathy associated with NMDA encephalitis is being increasingly recognised in the literature [2][3][4][5][6] and was reviewed most recently by Mugavin et al 2 in 2017. In this report, we present a case of bilateral optic neuropathy in a young man diagnosed with NMDA receptor encephalitis.…”