Dados do Trabalho

Título

Diagnostic challenges in Anti-NMDAr encephalitis: a case report

RESUMO

Case Presentation: A 29-year-old woman, lawyer, no comorbidities or psychiatric history, presented with agitation and insomnia. In few days, there was worsening of symptoms, associated with delusional speech and executive dysfunction. Present to psychiatry avaliation, with TAB diagnoses, Olanzapine started, but no improvement. After three weeks, the patient needs help for basic ativities. She presented perioral moviments and unexplained coma, with hospitalar addimission. The MRI, CSF, laboratory tests for infection and metabolismo were normal. Acyclovir started due to suspected herpetic encephalitis. The patient was transferred to a tertiary center, anti-NMDA encephalitis was suggested and a sample of CSF and serum was sent for antibody testing. Screening imaging and markers excluded teratoma or other occult neoplasms. Empirical treatment was started with methylprednisolone 1g daily for five days, followed by five sessions of phasmapheresis and rituximab. The tests has been found positive for NMDAr antibodies, and the pacient remains in intensive care for clinical support. Discussion: Autoimmune encephalitis is caused by the production of antibodies against neuronal autoantigens. It affects mostly young women, presenting with acute or subacute psychiatric symptoms, seizures, cognitive deficits, coma, and autonomic dysfunction. Often psychiatric symptoms are the initial symptoms and these patients are mistakenly treated as primary psychosis or mood disorders, leading to diagnostic delay and worse prognosis. The association of anti-NMDAr encephalitis with neoplasms is large, and investigation should be extensive, focusing on ovarian teratoma. Treatment primarily involves intensive care associated with immunosuppressive therapy. The first line constitutes corticoids, immunoglobulin or plasmapheresis. The second line of treatment is done in selected cases, usually in patients with late diagnosis or in those with no association with tumor, being Rituximab the drug of choice. For refractory cases, Bortezomib is third line. The prognosis is generally satisfactory, however, because it is a long-stay disease in the ICU, it is susceptible to several clinical and neurological complications throughout treatment. Final Comments: Anti-NMDA encephaltis should be considered as a diagnostic possibility in cases of subacute psychiatric alterations with neurological symptoms, and empiric treatment having to be considered for better therapeutic results.

Palavras Chave

Anti-NMDA encephaltis, psychiatric alterations, Autoimmune encephalitis