Case Presentation: A 33-year-old woman presented with self-inflicted stab wounds to her neck and abdomen. Though she was initially alert and following commands, she was unwilling to provide a medical history and only shared that she had been experiencing headaches for three weeks prior to presentation.Labs were unremarkable, but CT scan on admission showed right frontal lobe vasogenic edema surrounding an apparent ovoid mass measuring 2.5 cm. MRI showed a right parietal lobe lesion extending from the ependymal surface. The differential included tumefactive demyelination, progressive multifocal leukoencephalopathy, viral encephalitides, and malignancies including lymphoma or high-grade glioma. Lumbar puncture studies showed 5 WBC/hpf with 91% lymphocytes and an opening pressure of 29. CSF was also positive for 5 oligoclonal bands, NMDA receptor antibodies (high positive), and myelin oligodendrocyte glycoprotein (MOG) antibodies (1:40 titer). MR spectroscopy confirmed that the right parietal lobe lesion was a demyelinating lesion.While awaiting return of CSF results, the patient was minimally interactive and experienced intermittent rigidity accompanied by profound hypertension and tachycardia. The patient was started on scheduled benzodiazepines for malignant catatonia with good effect on her vital signs. She was also started on seven days of high-dose methylprednisolone with minimal effect on her mental status. She then completed five sessions of plasma exchange. Although still delirious, she became more conversational and no longer expressed thoughts of self-harm. Rituximab is planned for long-term management.
Discussion: Though acute psychosis is often associated with primary psychiatric disorders or underlying medical conditions, it can also be the presenting symptom in neuroimmunological disorders, including multiple sclerosis (MS) and anti-NMDA-receptor encephalitis (anti-NMDARE). In this case, we describe psychosis and self-inflicted laceration injuries that was eventually diagnosed as likely anti-NMDARE with overlapping tumefactive MS. She also had positive MOG antibodies, but she had no ocular symptoms or neuroradiologic findings of MOG Antibody Disease.While her clinical presentation was more consistent with anti-NMDARE, her imaging was indicative of a demyelinating process such as tumefactive MS. MS normally presents with asymmetric neurological defects. It is atypical for any brain lesion to present so psychotropically with suicidal ideation and self-harm in the absence of any neurological deficits. Taken together, her presentation is most consistent with profound inflammation secondary to anti-NMDARE associated with secondary demyelination and autoantibodies. While a brain biopsy could give a definitive answer, the lesion is in a high-risk area of her motor strip.
Conclusions: Neuroinflammation is a spectrum that can result in significant overlap in clinical presentation. Although definitive diagnoses are sometimes elusive, immunosuppresants such as rituximab can treat multiple potential diagnoses simultaneously.