Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a treatable autoimmune encephalitis that often presents with acute behavioral change or psychosis and rapidly evolves to dysautonomia, movement disorder, seizures, and decreased level of consciousness. We report a 26-year-old woman who presented to an Emergency Department (ED) with first-episode psychosis, autonomic instability, and orofacial dyskinesias. After an initial medical evaluation, the patient was referred to the ED Psychiatric Nurse Practitioner (NP), whose prompt application of a structured autoimmune-encephalitis diagnostic approach enabled expedited neurology consultation, cerebrospinal fluid (CSF) confirmation of anti-GluN1 antibodies, and early immunotherapy (steroids, plasma exchange, rituximab). At the three-month follow-up, she had resumed full-time work without psychotropic medication. This case underscores the value of structured diagnostic reasoning and early referral pathways in the emergency department.
References
[1]
Graus, F., Titulaer, M.J., Balu, R., Benseler, S., Bien, C.G., Cellucci, T., et al. (2016) A Clinical Approach to Diagnosis of Autoimmune Encephalitis. The Lancet Neurology, 15, 391-404. https://doi.org/10.1016/s1474-4422(15)00401-9
[2]
Titulaer, M.J., McCracken, L., Gabilondo, I., Armangué, T., Glaser, C., Iizuka, T., etal. (2013) Treatment and Prognostic Factors for Long-Term Outcome in Patients with Anti-NMDA Receptor Encephalitis: An Observational Cohort Study. The Lancet Neurology, 12, 157-165. https://doi.org/10.1016/s1474-4422(12)70310-1
[3]
Dalmau, J., Armangué, T., Planagumà, J., Radosevic, M., Mannara, F., Leypoldt, F., et al. (2019) An Update on Anti-NMDA Receptor Encephalitis for Neurologists and Psychiatrists: Mechanisms and Models. The Lancet Neurology, 18, 1045-1057. https://doi.org/10.1016/s1474-4422(19)30244-3
[4]
Gresa-Arribas, N., Titulaer, M.J., Torrents, A., Aguilar, E., McCracken, L., Leypoldt, F., et al. (2014) Antibody Titres at Diagnosis and during Follow-Up of Anti-NMDA Receptor Encephalitis: A Retrospective Study. TheLancetNeurology, 13, 167-177. https://doi.org/10.1016/s1474-4422(13)70282-5
[5]
Schmitt, S.E., Pargeon, K., Frechette, E.S., et al. (2012) Extreme Delta Brush: A Unique EEG Pattern in Adults with Anti-NMDA Receptor Encephalitis. Neurology, 79, 1094-1100.
[6]
Nosadini, M., Thomas, T., Eyre, M., Anlar, B., Armangue, T., Benseler, S.M., et al. (2021) International Consensus Recommendations for the Treatment of Pediatric NMDAR Antibody Encephalitis. Neurology Neuroimmunology & Neuroinflammation, 8, e1052. https://doi.org/10.1212/nxi.0000000000001052
[7]
Dalmau, J., Gleichman, A.J., Hughes, E.G., Rossi, J.E., Peng, X., Lai, M., et al. (2008) Anti-NMDA-Receptor Encephalitis: Case Series and Analysis of the Effects of Antibodies. The Lancet Neurology, 7, 1091-1098. https://doi.org/10.1016/s1474-4422(08)70224-2
[8]
Gong, X., Chen, C., Liu, X., et al. (2021) Long-Term Functional Outcomes and Relapse of Anti-NMDA Receptor Encephalitis: A Cohort Study in Western China. NeurologyNeuroimmunology&Neuroinflammation, 8, e958. https://doi.org/10.1212/nxi.0000000000000958
[9]
Tunkel, A.R., Glaser, C.A., Bloch, K.C., Sejvar, J.J., Marra, C.M., Roos, K.L., et al. (2008) The Management of Encephalitis: Clinical Practice Guidelines by the Infectious Diseases Society of America. ClinicalInfectiousDiseases, 47, 303-327. https://doi.org/10.1086/589747
[10]
Lancaster, E. (2016) The Diagnosis and Treatment of Autoimmune Encephalitis. Journal of Clinical Neurology, 12, 1-13. https://doi.org/10.3988/jcn.2016.12.1.1
[11]
Kvam, K.A., Stahl, J., Chow, F.C., Soldatos, A., Tattevin, P., Sejvar, J., et al. (2024) Outcome and Sequelae of Autoimmune Encephalitis. Journal of Clinical Neurology, 20, 3-22. https://doi.org/10.3988/jcn.2023.0242
[12]
Brenner, J., Ruhe, C.J., Kulderij, I., Bastiaansen, A.E.M., Crijnen, Y.S., Kret, C.N., etal. (2024) Long-Term Cognitive, Functional, and Patient-Reported Outcomes in Patients with Anti-NMDAR Encephalitis. Neurology, 103, e210109. https://doi.org/10.1212/wnl.0000000000210109
[13]
Mahadeen, A.Z., Carlson, A.K., Cohen, J.A., Galioto, R., Abbatemarco, J.R. and Kunchok, A. (2024) Review of the Longitudinal Management of Autoimmune Encephalitis, Potential Biomarkers, and Novel Therapeutics. Neurology Clinical Practice, 14, e200306. https://doi.org/10.1212/cpj.0000000000200306
[14]
Gao, Y., Zhang, Z., Liu, L., et al. (2023) Systematic Review: Clinical Characteristics of Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Frontiers in Human Neuroscience, 17, Article 1261638.
[15]
Ferreira, J.H.F., Disserol, C.C.D., de Freitas Dias, B., Marques, A.C., Cardoso, M.D., Silva, P.V.D.C., et al. (2024) Recent Advances in Autoimmune Encephalitis. Arquivos de Neuro-Psiquiatria, 82, 1-13. https://doi.org/10.1055/s-0044-1793933
