Case Presentation: A 34 year-old woman with no significant past medical or psychiatric history presented to our emergency department (ED) with concern for catatonia. Two months prior, the patient developed sudden onset of bizarre behavior, aggression, and psychosis leading to a one-month admission at an outside psychiatric hospital. She did not improve clinically despite treatment with dual antipsychotics and mood stabilizers and was admitted to our medicine service to evaluate psychosis with features of catatonia. The patient’s husband helped provide history; the patient herself noted only that she had “head stress” and “a snake in her pelvis.” There was no reported history of head trauma, alcohol or drug use, or family history of autoimmune/neurologic/malignant conditions. On exam, patient was alert but disoriented, exhibiting echolalia, paranoia, psychomotor slowing, and reduced oral intake. She had minimal improvement with escalating doses of lorazepam to treat suspected catatonia. Evaluation demonstrated normal leukocytes, hemoglobin, platelets, renal and hepatic function, a normal CT head, and lumbar puncture (CSF) with normal protein and glucose, 5 WBC, 6 RBC. Infectious work up was negative. MRI Brain demonstrated nonspecific findings of encephalitis, prompting initiation of IV methylprednisolone followed by IVIG and rituximab for suspected autoimmune encephalitis, with no clinical response. Given her age with new onset psychosis and treatment-refractory symptomatology, further imaging was ordered to investigate for potential paraneoplastic etiology. CT chest/abdomen/pelvis revealed pelvic lymphadenopathy, and MRI pelvis identified an exophytic cervical mass. Cervical biopsy confirmed stage IIIC2 cervical neuroendocrine tumor. CSF studies returned positive for NMDA receptor antibodies. Patient was initiated on chemotherapy and discharged for outpatient management. Two months after discharge, psychiatry noted she had normal neuropsychiatric function.
Discussion: Psychiatric conditions with features of psychosis are most commonly diagnosed in adolescence through early adulthood. Our patient’s acute onset of psychotic symptoms in her mid-thirties — refractory to antipsychotics and mood stabilizers—constitute alarm features that prompted further evaluation for an underlying medical cause. N-methyl-D-aspartate receptor (NMDAr) encephalitis is an autoimmune disorder that may be associated with a wide spectrum of neuropsychiatric symptoms, including psychosis, seizures, and catatonia. Approximately 38% of patients with NMDAr encephalitis have a paraneoplastic relationship, most commonly with ovarian teratomas. This case highlights an atypical presentation of paraneoplastic NMDAr encephalitis secondary to cervical neuroendocrine carcinoma. While cervical cancer is relatively common in reproductive-age females, its association with paraneoplastic autoimmune encephalitis is rare. Steroids and IVIG may temporize symptoms, but ultimate treatment is addressing the underlying cancer.
Conclusions: New onset psychosis at an atypical age and/or catatonia refractory to medical management warrants exploring a broad differential, including infectious, autoimmune, primary neurodegenerative, and paraneoplastic etiologies. Hospitalists should be aware of red flag features of psychosis and catatonia as a comprehensive workup can reduce morbidity associated with a missed or delayed neoplastic diagnosis.