Psychosis in the ED: A case of NMDA receptor antibody encephalitis

Published:February 06, 2017DOI:


      Anti-N-methyl-d-aspartate antibody receptor (NMDAR) encephalitis is a newly recognized disease increasing in diagnostic frequency. A 27-year-old female presented with symptoms of oral dyskinesia, tachycardia, and altered mental status following a three-month history of depression, lethargy, catatonia, and auditory hallucinations. We utilized our facilities neurology and psychiatry consult services, performed a lumbar puncture (LP), and requested NMDAR antibody titers. Following admission the Anti-NMDAR antibody titer was elevated warranting treatment with intravenous immunoglobulin (IVIG), corticosteroids, and later rituximab. Organic causes of psychosis are often overlooked in the emergency department, particularly in patients with a history of psychiatric illness. An understanding and awareness of NMDAR encephalitis allows for timely diagnosis, prompting quicker treatment. Emergency physicians should maintain an index of clinical suspicion for NMDAR encephalitis when encountering patients with progressive symptoms of catatonia and psychosis of unclear etiology.


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        • Titulaer M.J.
        • McCracken L.
        • Gabilondo I.
        • et al.
        Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study.
        Lancet Neurol. 2013; 12: 157-165
        • Kruse J.L.
        • Jeffrey J.K.
        • Davis M.C.
        • Dearlove J.
        • IsHak W.W.
        • Brooks 3rd., J.O.
        Anti-N-methyl-d-aspartate receptor encephalitis: a targeted review of clinical presentation, diagnosis, and approaches to psychopharmacologic management.
        Ann Clin Psychiatry. 2014; 26: 111-119
        • Wandinger K.P.
        • Saschenbrecker S.
        • Stoecker W.
        • Dalmau J.
        Anti-NMDA-receptor encephalitis: a severe, multistage, treatable disorder presenting with psychosis.
        J Neuroimmunol. 2011; 231: 86-91
        • Mohammad S.S.
        • Sinclair K.
        • Pillai S.
        • et al.
        Herpes simplex encephalitis relapse with chorea is associated with autoantibodies to N-methyl-d-aspartate receptor or dopamine-2 receptor.
        Mov Disord. 2014; 29: 117-122
        • Greiner H.
        • Leach J.L.
        • Lee K.H.
        • Krueger D.A.
        Anti-NMDA receptor encephalitis presenting with imaging findings and clinical features mimicking Rasmussen syndrome.
        Seizure. 2011; 20: 266-270
        • Dalmau J.
        • Gleichman A.J.
        • Hughes E.G.
        • et al.
        Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies.
        Lancet Neurol. 2008; 7: 1091-1098
        • Dalmau J.
        • Lancaster E.
        • Martinez-Hernandez E.
        • Rosenfeld M.R.
        • Balice-Gordon R.
        Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis.
        Lancet Neurol. 2011; 10: 63-74
        • Steiner J.
        • Walter M.
        • Glanz W.
        • et al.
        Increased prevalence of diverse N-methyl-d-aspartate glutamate receptor antibodies in patients with an initial diagnosis of schizophrenia: specific relevance of IgG NR1a antibodies for distinction from N-methyl-d-aspartate glutamate receptor encephalitis.
        JAMA Psychiat. 2013; 70: 271-278
        • Barry H.
        • Byrne S.
        • Barrett E.
        • Murphy K.C.
        • Cotter D.R.
        Anti-N-methyl-d-aspartate receptor encephalitis: review of clinical presentation, diagnosis and treatment.
        BJPsych Bull. 2015; 39: 19-23
        • Hughes E.G.
        • Peng X.
        • Gleichman A.J.
        • et al.
        Cellular and synaptic mechanisms of anti-NMDA receptor encephalitis.
        J Neurosci. 2010; 30: 5866-5875
        • Pruss H.
        • Dalmau J.
        • Harms L.
        • et al.
        Retrospective analysis of NMDA receptor antibodies in encephalitis of unknown origin.
        Neurology. 2010; 75: 1735-1739
        • Finke C.
        • Kopp U.A.
        • Pruss H.
        • Dalmau J.
        • Wandinger K.-P.
        • Ploner C.J.
        Cognitive deficits following anti-NMDA receptor encephalitis.
        • Weaver M.
        • Griffey R.T.
        Anti-N-methyl-d-aspartate receptor encephalitis as an unusual cause of altered mental status in the emergency department.
        J Emerg Med. 2016; 51: 136-139