Anti-NMDA receptor encephalitis: An emerging differential diagnosis in the psychiatric community

Abstract Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a new diagnosis, as recent as 2007, that develops as a result of autoantibodies to the NMDA receptor. The clinical manifestations of the disorder include complex psychiatric symptoms, seizures, movement disorders, cognitive dysfunction, and autonomic instability. Tumor resection, if present, and immunotherapy are the mainstays of therapy. Treatment should be initiated early and aggressively as it has been associated with better patient outcomes. A significant proportion of patients with anti-NMDA receptor encephalitis initially seek the help of a psychiatrist, highlighting the importance of its recognition within the mental health community. In an effort to promote disease awareness, this article will review a patient case and the pathophysiology, clinical presentation, diagnosis, and management of anti-NMDA receptor encephalitis.

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Anti-NMDA Receptor Encephalitis in a Patient with Previous Psychosis and Neurological Abnormalities: A Diagnostic Challenge

Case Reports in Psychiatry ◽

10.1155/2015/253891 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

R. David Heekin ◽

Maria C. Catalano ◽

Alfred T. Frontera ◽

Glenn Catalano

Keyword(s):

Nmda Receptor ◽

Psychiatric Symptoms ◽

Neuropsychiatric Symptoms ◽

Memory Loss ◽

Autoimmune Disorder ◽

Diagnostic Challenge ◽

Manic Symptoms ◽

Nmda Receptor Encephalitis ◽

Autonomic Instability ◽

Receptor Antibodies

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune disorder characterized by IgG autoantibodies directed against the NR1 subunit of the NMDA glutamate receptor. Psychiatric symptoms are common and include psychosis, mania, depressed mood, aggression, and speech abnormalities. Neurological symptoms such as seizures, decreased responsiveness, dyskinesias, and other movement abnormalities and/or autonomic instability are frequently seen as well. We present the case of a woman who was followed up at our facility for over 14 years for the treatment of multiple neuropsychiatric symptoms. Initially, she presented with paresthesias, memory loss, and manic symptoms. Nine years later, she presented to our facility again, this time with left sided numbness, left eyelid droop, and word finding difficulties. Finally, five years later, she presented with manic symptoms, hallucinations, and memory impairment. During her hospitalization, she subsequently developed catatonic symptoms and seizures. During her stay, it was discovered that she was positive for anti-NMDA receptor antibodies and her symptoms responded well to appropriate therapy. This case demonstrates that it may be useful for clinicians to consider screening for anti-NMDA receptor antibodies in long-term patients with neuropsychiatric symptoms that have not adequately responded to therapy.

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Phylogenetic Analysis to Explore the Association Between Anti-NMDA Receptor Encephalitis and Tumors Based on microRNA Biomarkers

Biomolecules ◽

10.3390/biom9100572 ◽

2019 ◽

Vol 9 (10) ◽

pp. 572 ◽

Cited By ~ 2

Author(s):

Wang

Keyword(s):

Phylogenetic Analysis ◽

Nmda Receptor ◽

Phylogenetic Trees ◽

Tumor Resection ◽

Autoimmune Disorder ◽

Control Of Gene Expression ◽

Nmda Receptor Encephalitis ◽

Nmdar Encephalitis ◽

Non Coding Rna ◽

The Relationship

MicroRNA (miRNA) is a small non-coding RNA that functions in the epigenetics control of gene expression, which can be used as a useful biomarker for diseases. Anti-NMDA receptor (anti-NMDAR) encephalitis is an acute autoimmune disorder. Some patients have been found to have tumors, specifically teratomas. This disease occurs more often in females than in males. Most of them have a significant recovery after tumor resection, which shows that the tumor may induce anti-NMDAR encephalitis. In this study, I review microRNA (miRNA) biomarkers that are associated with anti-NMDAR encephalitis and related tumors, respectively. To the best of my knowledge, there has not been any research in the literature investigating the relationship between anti-NMDAR encephalitis and tumors through their miRNA biomarkers. I adopt a phylogenetic analysis to plot the phylogenetic trees of their miRNA biomarkers. From the analyzed results, it may be concluded that (i) there is a relationship between these tumors and anti-NMDAR encephalitis, and (ii) this disease occurs more often in females than in males. This sheds light on this issue through miRNA intervention.

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Frequency and temporal sequence of clinical features in adults with anti-NMDA receptor encephalitis presenting with psychiatric symptoms

Psychological Medicine ◽

10.1017/s0033291718003665 ◽

2018 ◽

Vol 49 (16) ◽

pp. 2709-2716 ◽

Cited By ~ 3

Author(s):

Ronald J. Gurrera

Keyword(s):

Nmda Receptor ◽

Clinical Features ◽

Psychiatric Symptoms ◽

Autoimmune Encephalitis ◽

Signs And Symptoms ◽

Nmda Receptor Encephalitis ◽

Nmdar Encephalitis ◽

Unexplained Fever ◽

Study Inclusion

AbstractBackgroundAnti-NMDA receptor (NMDAr) encephalitis is the most common autoimmune encephalitis in adults. It mimics psychiatric disorders so often that most patients are initially referred to a psychiatrist, and many are misdiagnosed. Without prompt and effective treatment, patients are likely to suffer a protracted course with significant residual disability, or death. This study focuses on the frequency and chronology of salient clinical features in adults with anti-NMDAr encephalitis who are likely to be first evaluated by a psychiatrist because their presentation suggests a primary psychiatric disorder.MethodsA systematic search of PubMed and EMBASE databases identified published reports of anti-NMDAr encephalitis associated with prominent behavioral or psychiatric symptoms. After eliminating redundancies, the frequencies and relative timing of clinical features were tabulated. Signs and symptoms were assigned temporal ranks based on the timing of their first appearance relative to the first appearance of other signs and symptoms in each patient; median ranks were used to compare temporal sequencing of both individual features and major symptom domains.ResultsTwo hundred thirty unique cases (185 female) met study inclusion criteria. The most common features were seizures (60.4%), disorientation/confusion (42.6%), orofacial dyskinesias (39.1%), and mutism/staring (37.4%). Seizures, fever, and cognitive dysfunction were often the earliest features to emerge, but psychiatric features predominated and sequencing varied greatly between individuals.ConclusionsClinicians should consider anti-NMDAr encephalitis when new psychiatric symptoms are accompanied by a recent viral prodrome, seizures or unexplained fever, or when the quality of the psychiatric symptoms is unusual (e.g. non-verbal auditory hallucinations).

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Anti-NMDAR Encephalitis: Higher Suspicious Needed for Earlier Diagnosis (Case Report, Literature Review and Diagnostic Criteria)

Case Reports in Neurological Medicine ◽

10.1155/2019/7476254 ◽

2019 ◽

Vol 2019 ◽

pp. 1-5

Author(s):

Chanaka Amugoda ◽

Noushin Chini Foroush ◽

Hamed Akhlaghi

Keyword(s):

Mental Health ◽

Emergency Department ◽

Nmda Receptor ◽

Psychiatric Symptoms ◽

Health Assessment ◽

Young Patients ◽

Psychotic Episode ◽

Acute Psychosis ◽

Nmda Receptor Encephalitis ◽

Immune Mediated

Background. Auto-immune mediated anti-NMDA receptor encephalitis is a very common delayed diagnosed encephalitis which predominately affecting young population. Objectives. This encephalitis is relatively unknown amongst emergency physicians and a majority of patients are admitted to psychiatric wards before their diagnosis is confirmed and appropriate treatments are commenced. We reported a case of a 22-year-old female presented to our emergency department with acute psychiatric symptoms. She was initially diagnosed with first presentation of acute psychosis and was hospitalised under mental health act. further assessment in the emergency department identified possible an organic cause for her acute psychosis and she was later admitted under medical team after her mental health assessment order was revoke. Several days later, her CSF result was positive with anti-NMDA receptor anti-bodies. Appropriate treatments were instituted leading to her full recovery. Conclusion. This case was the first confirmed anti-NMDA receptor encephalitis in our emergency department. It highlights the importance of thorough assessment of psychiatric presentations to emergency departments and consideration of auto-immune medicated encephalitis as one of the differential diagnosis in young patients presenting with first acute psychotic episode.

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Anti-NMDA Receptor Encephalitis with a Favorable Prognosis Despite Delayed Treatment Due to Longstanding Psychiatric Symptoms

Movement Disorders Clinical Practice ◽

10.1002/mdc3.12095 ◽

2014 ◽

Vol 1 (4) ◽

pp. 386-387

Author(s):

Seung Woo Kim ◽

Hyung Seok Lee ◽

Phil Hyu Lee ◽

Sun-Ah Choi

Keyword(s):

Nmda Receptor ◽

Psychiatric Symptoms ◽

Delayed Treatment ◽

Favorable Prognosis ◽

Nmda Receptor Encephalitis

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Psychiatric Symptoms in a Patient with NMDA Receptor Encephalitis

Journal of Psychiatrists Association of Nepal ◽

10.3126/jpan.v9i1.31343 ◽

2020 ◽

Vol 9 (1) ◽

pp. 66-68

Author(s):

L Paudel ◽

S Samadarshi ◽

S Limbu ◽

R Sharma ◽

P Chalise ◽

...

Keyword(s):

Psychiatric Symptoms ◽

Autoimmune Disorder ◽

Behavioral Changes ◽

Psychiatric Consultation ◽

Course Of Illness ◽

Nmda Receptor Encephalitis ◽

Abnormal Movements ◽

Aspartate Receptor ◽

Autonomic Instability ◽

Psychiatric Manifestations

Anti N methyl D aspartate receptor (NMDA-R) encephalitis is an autoimmune disorder that encompasses various psychiatric and neurological symptoms. Psychiatric manifestations are often the presentation of the disease that often delay or mislead the diagnosis. Complex psychiatric symptoms, seizures, autonomic instability, abnormal movements, behavioral changes and impaired cognitive functions are present during the course of illness. Prodromal psychiatric symptoms often confuse the physicians and even patient initially seeks psychiatric consultation. Here we present a case of 19 years female who presented with initial psychiatric symptoms that progressed to seizure, autonomic instability, abnormal movement and other encephalitic symptoms.

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A 24-Year-Old Female With Anti-NMDA Receptor Encephalitis: A Case Report.

10.21203/rs.3.rs-105688/v1 ◽

2020 ◽

Author(s):

Antoine Steeman ◽

Ionut-Adrian Andriescu ◽

Guy Mazairac

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Nmda Receptor ◽

Psychiatric Symptoms ◽

Delayed Diagnosis ◽

Young Patients ◽

Tumour Resection ◽

Female Ratio ◽

Nmda Receptor Encephalitis ◽

Initial Symptoms

Abstract Background: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a form of autoimmune encephalitis with paraneoplastic and nonparaneoplastic origin. Patients with this disease usually arrive at the intensive care unit without any diagnosis or with complications as a result of a delayed diagnosis. This disease is not well known and is underdiagnosed. Due to the variability of the initial symptoms and the lack of knowledge regarding these symptoms, anti-NMDA receptor encephalitis is not only underdiagnosed but also can be misdiagnosed as viral encephalitis or other pathologies. Anti-NMDA receptor encephalitis preferentially affects children (from 8 months) and young adults, and it has a male/female ratio of 1/4. In case of clinical suspicion, electroencephalogram (EEG) and brain magnetic resonance imaging (MRI) are useful. The diagnosis is confirmed by the detection of IgG antibodies directed against NMDA receptors in serum and CSF. Treatment for this disease includes immunosuppression and tumour resection when indicated.Case presentation: We report the case of a 24-year-old female admitted to the emergency room following the onset of acute confusion. Due to the rapid deterioration of consciousness and swallowing disorders, the patient was transferred to the intensive care unit. On day 23 after presentation, MRI suggested autoimmune limbic encephalitis. Serologic and CSF results were positive for anti-NMDA antibodies. After IV methylprednisolone therapy and plasmapheresis and a second line therapy with corticosteroid therapy and mycophenolic acid, the patient’s clinical condition gradually improved.Conclusions: Anti-NMDA receptor encephalitis typically occurs in young patients with no history of acute psychiatric symptoms. The possibility of this pathology should be taken into account before diagnosing a patient with a psychiatric illness.

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