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 Table of Contents    
LETTERS TO EDITOR  
Year : 2021  |  Volume : 63  |  Issue : 2  |  Page : 209-210
Nonparaneoplastic anti-NMDA receptor autoimmune encephalitis presenting as psychosis: A case report


1 Department of Neurology, Gauhati Medical College, Guwahati, Assam, India
2 Department of Psychiatry, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, India

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Date of Submission26-Jan-2020
Date of Decision08-Mar-2020
Date of Acceptance17-Apr-2020
Date of Web Publication14-Apr-2021
 

How to cite this article:
Das M, Patra AK, Chakravarty PJ. Nonparaneoplastic anti-NMDA receptor autoimmune encephalitis presenting as psychosis: A case report. Indian J Psychiatry 2021;63:209-10

How to cite this URL:
Das M, Patra AK, Chakravarty PJ. Nonparaneoplastic anti-NMDA receptor autoimmune encephalitis presenting as psychosis: A case report. Indian J Psychiatry [serial online] 2021 [cited 2021 May 12];63:209-10. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/2/209/313721




Sir,

A 12-year-old adolescent girl without a history of psychiatric illness had presented with sudden-onset behavioral abnormalities such as abnormal posturing and stereotypic movement of the upper limb in a fluctuating manner. She also started withdrawing herself from surrounding and people. When the parents tried to console her, she used to address them as uncle and aunt living nearby and reject them as her parents. During conversation, she would often repeat the sentences spoken by the other person, but her verbal output reduced. Gradually, she started having formed visual as well as auditory hallucinations in the form of gods and goddesses.

Her sleep was disturbed, and also, she had autonomic disturbances in the form of hot sensation in chilling winter season, for which the family had to sit under the fan even during winter. There were episodes of flushing of face with abnormal sweating in winter. She used to eat only when given. There were bouts of rage and inconsolable cry with emotional lability. Recent memory was impaired, and she was unaware of her illness.

The family started believing about some black magic on her. She was initially admitted to the psychiatry unit and later to our neurology unit. Apart from higher mental functions, her neurological findings were normal. Routine investigation along with thyroid function was normal. Brain imaging revealed T2 hyperintensity in the right hippocampus while electroencephalogram had diffuse cortical slowing [Figure 1]. Routine cerebrospinal fluid (CSF) study was done to rule out infections. ANA and other autoantibody panel were normal [Table 1].
Figure 1: Magnetic resonance imaging T2 hyperintensity in the right hippocampus

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Table 1: Cerebrospinal fluid analysis findings

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Anti-NMDA receptor (NMDAR) antibody on the CSF found to be strongly positive. She was fulfilling the criteria for both autoimmune disease and anti-NMDAR autoimmune encephalitis. She received five doses of high-dose pulse corticosteroid therapy followed by prednisolone 1 mg/kg body weight/day. There was significant improvement with minimal emotional lability left at the end of 1st week. Contrast-enhanced computed tomography of the abdomen was done to rule out ovarian teratoma and it was normal.


   Discussion Top


Any patient with acute-onset psychosis without prior history of psychiatric illness with or without neurological symptoms of seizure, insomnia, autonomic instability, memory or speech impairment may be a case of autoimmune encephalitis.[1] Anti-NMDAR encephalitis had predominantly psychiatric manifestations, even purely psychiatric features sometimes.[2] Baker et al. reported a similar case of young female with hallucination, insomnia, and memory impairment having paraneoplastic anti-NMDAR autoimmune encephalitis.[3] Reji et al. reported a patient with similar episodes of repeated hospitalization with seizure and fluctuating behavioral abnormality.[4] In our case, it came out to be a nonparaneoplastic anti-NMDAR antibody autoimmune encephalitis.


   Conclusion Top


Every patient especially young with no prior history of psychiatric illness presenting with acute-onset psychosis or behavioral abnormality with or without seizure, memory or speech impairment should be screened for autoimmune encephalitis as there is always a high chance of having this curable entity which can be fatal if misdiagnosed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given her consent for her images and other clinical information to be reported in the journal. The patient's parents understand that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Day GS, High SM, Cot B, Tang-Wai DF. Anti-NMDA-receptor encephalitis: Case report and literature review of an under-recognized condition. J Gen Intern Med 2011;26:811-6.  Back to cited text no. 1
    
2.
Ford B, McDonald A, Srinivasan S. Anti-NMDA receptor encephalitis: A case study and illness overview. Drugs Context 2019;8:212589.  Back to cited text no. 2
    
3.
Baker J, Jeziorkowski C, Siebe C, Osborn MB. Two cases of anti-NMDA receptor encephalitis. West J Emerg Med 2016;17:623-6.  Back to cited text no. 3
    
4.
Reji R, Alexander S, Vijayan M. A case series on anti NMDAR encephalitis. Int J Pharm Pharma Sci 2017;9:220.  Back to cited text no. 4
    

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Correspondence Address:
Pranjal Jyoti Chakravarty
Department of Psychiatry, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_63_20

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