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A6865 - A Case of Anti-NMDA Encephalitis in the ICU
Author Block: K. Tsui, B. Ramgopal, K. Pollard, P. Aguilar; Division of Pulmonary/Critical Care, Washington University School of Medicine, St. Louis, MO, United States.
INTRODUCTION: Anti-NMDA encephalitis is an autoimmune encephalitis caused by antibodies against NMDA receptors that results in seizures, psychosis, dyskinesia, central hypoventilation, and autonomic instability. It is classically seen as a paraneoplastic syndrome associated with ovarian teratomas. We describe a case of anti-NMDA encephalitis admitted to the MICU for severe encephalopathy complicated by multi-organ system failure and persistent seizures. DESCRIPTION: The patient is a 28 year old female accountant who developed new onset seizures characterized by absence spells, head turning, and upper extremity shaking. EEG and brain MRI were unrevealing. She was started on levetiracetam but continued to have seizures and was switched to carbamazepine. She subsequently developed hallucinations and underwent inpatient psychiatric evaluation out of concern for non-epileptic events. She was treated with olanzapine and haloperidol but became progressively obtunded over the next two days. She was brought to the ED where she had convulsive seizures, a temperature of 107 ℉, creatinine kinase of 24,320 units/L, and acute renal failure. She was intubated and admitted to the MICU. She was given bromocriptine for possible NMS but did not improve. LP revealed 21 nucleated cells (90% lymphocytes), glucose 95 mg/dl, 0 RBCs, and elevated protein 24 mg/dl. LP gram stain/culture and CSF HSV PCR were negative. Ultimately, CSF anti-NMDA receptor antibody was positive with 5 oligoclonal bands. Continuous EEG showed moderate generalized slowing and delta brush consistent anti-NMDA encephalitis. MRI brain was normal. CT chest, abdomen, pelvis did not reveal evidence of an underlying malignancy. The patient was treated with methylprednisolone 1g x5 days and rituximab 700 mg x1. Despite this the patient continued to have dysautonomia resulting in cardiac arrest. At this point, she is recovering in the intensive care unit. DISCUSSION: Anti-NMDA encephalitis is a rare but potentially reversible cause of non-infectious encephalopathy, seizures, and psychosis that can be associated with NMS. This requires a high index of suspicion as EEG and MRI of the brain can be normal, leading to delays in diagnosis and treatment. Treatment options include IV corticosteroids, IVIG, plasmapheresis, rituximab, and/or cyclophosphamide.