Article

Pearls & Oy-sters: electroconvulsive therapy in anti-NMDA receptor encephalitis.

Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.
Neurology (Impact Factor: 8.3). 09/2010; 75(10):e44-6. DOI: 10.1212/WNL.0b013e3181f11dc1
Source: PubMed
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    ABSTRACT: Background Anti-N-methyl-D-aspartate (NMDA) receptor antibody encephalitis is becoming an increasingly recognized cause of encephalopathy in cases previously presumed to be viral encephalitis. Various manifestations of this disease include altered mental status, behavior changes, seizures, and movement disorders. We have noted three distinct subtypes of this disease which appear to have differential responses to immunotherapies as well as differences in prognosis. Methods And Patients: We report a case series of eight patients observed at our children’s hospital from 2009 through 2013 that appear to clearly fall into one of our three clinical categories. To find comparable articles reflecting this classification, we then performed a Medline search of all articles involving the subject heading ‘anti-NMDA receptor encephalitis’ or just the keyword phrase ‘NMDA encephalitis’ and we found 162 articles to review. 22 articles were eliminated for being basic science in focus, and we were able to 105 of the remaining articles, most of which were case reports or case series, although a few were larger reviews. For the sake of our review, we defined type 1 or “classic” anti-NMDA receptor antibody encephalitis as having a duration less than 60 days and being characterized predominantly by a catatonic or stuporous state, type 2 or psychiatric-predominant anti-NMDA receptor antibody encephalitis as having no notable catatonic or stuporous state in addition to the presence of predominantly behavioral/psychiatric symptoms, and type 3 or catatonia-predominant anti-NMDA receptor antibody encephalitis as having a duration of 60 days or longer of being in a predominantly catatonic or stuporous state. Results We note that the poorest responders, even to aggressive immunotherapies, are the catatonia persistent type anti-NMDA receptor antibody encephalitis, which has as its hallmark, prolonged periods of severe encephalopathy. Patients with predominantly psychiatric symptoms, which we call the psychiatric predominant NMDA receptor antibody encephalitis, have had excellent responses to plasma exchange or other immunotherapies and appear to have the least residual deficits at follow-up. Patients with fairly equal representations of periods of altered mental status, behavior problems, and movement disorders appear to have an intermediate prognosis and likely require early aggressive immunotherapy. Conclusions In our case series, we discuss representative examples of these clinical subtypes and their associated outcomes, and we suggest that tracking these subtypes in future cases of anti-NMDA receptor antibody encephalitis might lead to better understanding and better risk stratification with regards to immunotherapy decisions.
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    ABSTRACT: Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune disorder, often paraneoplastic in nature, presenting with complex neuropsychiatric symptoms. Diagnosed serologically, this disorder is often responsive to immunosuppressant treatment. The objective of this review is to educate clinicians on the challenges of diagnosis and management of this disorder.
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    ABSTRACT: Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis, first characterized in 2005, is a neurological disease with prominent psychiatric features that frequently involves the consultation of psychiatrists. Since its discovery, the rate of diagnosis of new cases has increased rapidly and several epidemiological studies now confirm that NMDA-R encephalitis may be as common as many other prominent infectious etiologies of encephalitis. We describe a case of a young woman presenting initially with psychotic and mood symptoms who was found to have anti-NMDA-R encephalitis. We further provide details of her treatment and prolonged recovery process after hospital discharge with a review of the literature and discussion of the epidemiology, symptomology, diagnosis, and management of both the neurologic and psychiatric manifestations of this condition. Last, we contextualize the importance of anti-NMDA-R encephalitis for psychiatrists, highlighting the role for psychiatrists in establishing the initial diagnosis as well as in providing ongoing psychiatric care.
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