A 26 year old female with no past medicalor psychiatric history presented to our hospital by her friends after they reported complaining that she had been behaving impulsive and manic during the preceding week. As described by friends and family, patient had recently traveled from Arkansas to Chicago to visit her family. However she was acting progressively more unusual with extreme swinging emotional liability with hysteric laughing and crying spells.
Considering her symptoms to be secondary to Bipolar disorder, she was admitted to the inpatient psychiatry unit initially and treated with anti- psychotics and mood stabilizers including Haloperidol, Quetiapine and Lithium. However on the next day, she had become severely confused, hypertensive and tachycardiac with significant muscular stiffness and was found to have an elevated CK of 5000 IU/L. She was then transferred to the inpatient medical floor for concern of having developed the management of possible Neuroleptic Malignant Syndrome.
During the course of her hospitalization, she continued to deteriorate. Her behavior was bizarre and she developed regressed child-like speech, echolalia and hyperorality. She was also showing signs of audiovisual hallucinations. Neurology and Infectious disease were consulted. Infectious processes such as encephalitis and CNS infections were considered and an LP was performed – that, although ruled out CNS infection, did surprisingly come back positive for anti-NMDA receptor antibodies. Subsequently, she received an initial round of high dose steroids, followed by IVIG with minimal clinical improvement.
Since the most common etiology of NMDAR encephalitis in a young female is an ovarian tumor, she underwent abdominal imaging and was found to have a large 12 cm teratoma on her ovary, hence laparascopic salphinoopherectomy was performed within a few days of diagnosis and the biopsy was confirmatory.
After a second round of high dose steroids she had started to make a gradual improvement in terms of mental status and responsiveness with decreasing catatonia and was transferred to the acute inpatient rehabilitation unit. After an intense period of rehabilitative therapy lasting several weeks, she made remarkable recovery with mild mood and cognitive deficits at the time of discharge.
Discussion:
NMDA Receptor encephalitis presenting with alerted mental status and catatonia may deviate diagnosis towards psychiatric illnesses. As the psychiatric symptoms are often the most prominent with acute presentation of NMDAR encephalitis, 77% of patients are initially seen by psychiatrists (Mann et al., 2014), and many patients are diagnosed with new-onset psychiatric disorders. Prompt diagnosis with relevant clinical and diagnostic tools including removal of the teratoma may lead to complete recovery.
Conclusions:
It is of paramount importance that organic causes of psychosis to be ruled out especially in the absence of any supporting evidence, and hospitalists should be aware of such entity.