A case of sudden psychosis
After her mother dies, Ms. T develops mania and disorganized behavior. She has a seizure and becomes increasingly agitated. Is this grief or something else?
5 Ms. T spent time on psychiatric, internal medicine, and neurologic services before her team established a definitive diagnosis.
Because neurobehavioral symptoms predominate early in the course of paraneoplastic illness,5 psychiatrists should prepare to be the first medical point of contact for these patients.
Table 2
Anti-NMDA receptor encephalitis: Symptoms, findings, and treatment
| Typical presentation |
| Young female Prodromal symptoms New onset psychosis, anxiety, or mood symptoms Catatonia Coma Seizure activity (typically bilateral temporal lobe activity on EEG) Hypoventilation Autonomic instability Dyskinesia |
| Laboratory and radiologic findings |
| CSF or serum antibodies CSF pleocytosis and elevated protein, normal glucose Background slowing or sharp-wave activity on EEG Temporal lobe abnormalities |
| Treatment |
| Tumor resection Immunosuppressants (typically corticosteroids) Intravenous immunoglobulin Plasmapheresis |
| CSF: cerebrospinal fluid; EEG: electroencephalography; NMDA: N-methyl-D-aspartate |
Box
Neurology. Several case reports in neurologic literature describe presentations similar to Ms. T’s.
Sansing et al8 described a 34-year-old woman with prominent psychiatric symptoms who had an immature ovarian teratoma with positive anti-NMDA (N-methyl-D-aspartate) receptor antibody. She was treated with tumor resection, plasmapheresis, and corticosteroids and experienced significant improvement.
Nasky et al7 describe a 23-year-old woman with paranoia, agitation, and delusions. A neoplasm was not identified, but she was anti-NMDA receptor antibody positive and improved with IV corticosteroids and IV immunoglobulin.
Dalmau et al5 compiled a case series analysis of 100 cases of anti-NMDA receptor encephalitis. Tumor removal with IV corticosteroids, IV immunoglobulin, and plasma exchange were the most common treatments. Patients with tumors that were identified and resected had better functional recovery than those without tumor resection.5
Psychiatry. A search of psychiatric literature yielded only 2 pertinent case reports. Lee et al9 described an 11-year-old girl with acute confusion, agitation, paranoia, hallucinations, and later malignant catatonia that improved after removal of an ovarian teratoma. Seki et al10 reported on an 18-year-old woman who presented with schizophrenia-like symptoms of disorganization and loss of self awareness. This patient’s symptoms resolved almost completely after unilateral salpingo-oophorectomy, corticosteroid administration, and plasma exchange.
- Dalmau J, Rosenfeld MR. Paraneoplastic syndromes of the CNS. Lancet Neurol. 2008;7(4):327-340.
- Fosphenytoin • Cerebyx
- Haloperidol • Haldol
- Levetiracetam • Keppra
- Lorazepam • Ativan
- Methylprednisolone • Medrol, Depo-Medrol, others
- Olanzapine • Zyprexa
- Prednisone • Deltasone, Meticorten
- Ziprasidone • Geodon
Drs. Cavalieri and Southammakosane report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. White is a consultant for Pfizer Inc.
