Dados do Trabalho

Título

Autoimmune encephalitis as a diferential diagnosis in a woman with a new onset psychiatric behavior

Apresentação do caso

A 53 year old patient, without previous comorbidities, presents with fever associated with headache for 5 days with spontaneous resolution. 1 week later, started to show psychiatric behavior, seizures, and visual hallucinations with progressive worsening. Patient admitted febrile, with inappropriate behavior, without signs of meningeal irritation or focal neurological deficits. Brain CT showed no changes. CSF was performed, demonstrating mild pleocytosis (12 cell - 97% lympho)| Prot: 32| Gluc: 93|. Acyclovir was introduced, associated with ceftriaxone+ampicillin. 1 day later, the patient evolved with refractory status epilepticus, so the patient was transferred to the ICU. 4 days later, the patient showed no improvement, presenting EEG with lateralized periodic activity. New CSF 4 days later showed 8 cells (97 %lympho)| Prot: 41| Gluc: 74. Brain MRI demonstrated hyperintensity in the mesial region of temporal lobes bilaterally. Autoimmune encephalitis was raised, then methylprednisolone was performed for 5 days, with partial response but with persistence of disorientation and inappropriate behavior. Cyclophosphamide was perform, with clinical improvement, but reported a amnestic deficit. Antibody panel for autoimmune encephalitis, rheumatological profile and neoplastic screening were searched, without alterations. The patient was discharged 1 week later. On reassessment, the patient didn’t present recurrence of seizures, but remained with amnestic complain, being referred for rehabilitation.

Discussão

Autoimmune encephalitis is a serious clinical condition, with a lower incidence in comparation to infectious etiologies, requiring early diagnosis and treatment for a better prognosis. Diagnosis requires: subacute onset over less than 3 months of working memory deficits, mental status, or altered psychiatric symptoms; at least one of the following: new focal CNS findings, seizures not explained by a preexisting disorder, CSF pleocytosis, and/or MRI features suggestive of encephalitis; and reasonable exclusion of alternative causes.

Comentários finais

Considering the negative potential of untreated autoimmune encephalitis, this should always be considered as a differential diagnosis in patients with clinical signs of encephalitis, especially in those patients who don’t respond adequately to the initial empirical therapies.