Extreme Delta Brush in NMDA Receptor Encephalitis

A 24-year-old female presented with 2 days of confusion and memory impairment and quickly progressed to a comatose state with dyskinetic movements. Initial cerebrospinal fluid results were notable for a lymphocytic pleocytosis. Initial electroencephalograms showed diffuse slowing and extreme delta brush pattern (Figure 1). Contrast-enhanced magnetic resonance imaging (MRI) of the brain did not reveal acute pathology. A possible hemorrhagic cyst in the left ovary was noted on pelvis MRI. One week after initial presentation, NMDAr antibody reported as positive. Patient’s treatment regimen consisted of high-dose intravenous steroids, plasma exchange, rituximab induction, numerous combinations of antiepileptic drugs, and unilateral oophorectomy. Despite the presence of indeterminate pathology on pelvic imaging, no evidence of neoplasm, teratoma or otherwise, was discovered. Unfortunately, the patient did not show much clinical improvement over her 6-month hospitalization