A 42 year old male with no significant medical history was brought by family to the emergency department for evaluation of confusion, dizziness, slurred speech, difficulty with cognition, and symptoms of an upper respiratory infection. In addition the patient began suffering from visual hallucinations and paranoid behavior. The patient had no past psychiatric history nor familial history of cerebrovascular or psychiatric disease. Patient and family members denied use of tobacco, alcohol, or illicit drugs as well as other drugs of abuse such as synthetic marijuana.
On physical exam the patient was exhibiting bizarre behavior with occasional dysarthria. He did not exhibit symptoms of meningitis on exam. Laboratory data noted initial WBC of 15.1 with a mild elevation of serum creatinine at 1.37. Urine drug screen was negative. TSH and CRP were within normal limits. Lumbar puncture revealed 44 WBC with CSF glucose of 59 and protein of 28. Head CT and MRI were both noted to be negative studies. EEG was done that noted temporal slowing.
Despite antipsychotic regimen per recommendations of psychiatry, patient continued to exhibit bizarre behavior with no improvement. Furthermore, the patient complained of a myriad of somatic complaints including visual changes. In consultation with neurology it was felt that that the patient was suffering from encephalitis and steroid therapy was initiated. This resulted in slow but steady improvement in the patient’s behavior. Patient’s CSF was sent for antibody testing and patient was found to be positive for anti-NMDA receptor antibodies. IVIG treatment was initiated and in conjunction with steroids and antipsychotic medications the patient returned to baseline.
Discussion:
In this case, the patient’s prolonged and progressive altered mental state in conjunction with elevated WBC on CSF sampling raised the question of possible encephalitis. Anti-NMDA receptor encephalitis is rare cause of altered mental status, however, our patient did exhibit common findings of this diagnosis. The patient presented with flu-like symptoms as well as changes in behavior and cognition, all of which are common manifestations of the disease. Of note, however, the patient’s presentation had some unique features. It is often found to be a paraneoplastic manifestation of a teratoma or ovarian tumor as well as primarily occurring in females. After extensive work up, no malignancy was found in our male patient.
Conclusions:
Anti-NMDA receptor encephalitis is a rare-cause of acute psychosis. It should be considered in cases where standard treatment does not result in expected psychiatric improvement.