Introduction: Encephalitis due to anti-NMDA receptor antibodies is an acute and severe condition, which, if identified and treated quickly, can entail recovery without any sequelae. It is more prevalent in young females and is often associated with an underlying tumour. The initial symptoms are usually of a psychiatric nature, and in a matter of days or weeks take on a characteristic neurological profile.
Case reports: We report the cases of three women, 17, 23 and 35 years of age, who were admitted to Psychiatry with acute psychotic clinical features. The poor response to antipsychotics, the fluctuations in the level of consciousness, dysautonomia and epileptic seizures were the symptoms that led to the clinical suspicion. The cerebrospinal fluid revealed slight pleocytosis and gave positive for anti-NMDA receptor antibodies in all cases. Only one patient displayed alterations in the magnetic resonance brain scan, and in two cases there was an extreme delta brush electroencephalographic pattern. All three women were diagnosed with an ovarian teratoma which was resectioned within a month. Two of the patients recovered without any sequelae, and the third presents cognitive sequelae six months after being discharged.
Conclusions: The cases described began with an acute psychotic clinical picture. The atypical psychiatric progression and the neurological symptoms indicated the possible presence of encephalitis. Recognition of the disease and coordination among the different services is essential for early diagnosis and treatment. The systematic analysis of cerebrospinal fluid in patients with a first acute-subacute psychotic episode would help to reach a diagnosis sooner. In young women, a search must always be carried out for an ovarian teratoma or other associated tumour.
Title: Encefalitis antirreceptor de NMDA. Diagnostico y tratamiento precoz en pacientes con sintomatologia psicotica aguda-subaguda.
Introduccion. La encefalitis por anticuerpos antirreceptor de NMDA es una entidad aguda y grave, cuya rapida identificacion y tratamiento puede comportar recuperaciones sin secuelas. Es mas prevalente en mujeres jovenes y a menudo esta asociada a un tumor subyacente. Los sintomas iniciales son habitualmente psiquiatricos y en dias o semanas adquieren el perfil neurologico caracteristico. Casos clinicos. Tres mujeres, de 17, 23 y 35 años, que ingresaron en el Servicio de Psiquiatria con clinica psicotica aguda. La mala respuesta a los antipsicoticos, las fluctuaciones del nivel de conciencia, la disautonomia y las crisis epilepticas fueron los sintomas que despertaron la sospecha clinica. El liquido cefalorraquideo mostro leve pleocitosis y positividad para los anticuerpos antirreceptor de NMDA en todas las pacientes. Solo una mostro alteraciones en la resonancia magnetica cerebral, y dos, el patron electroencefalografico extreme delta brush. En todas se diagnostico un teratoma ovarico, que fue resecado antes del mes. Dos se recuperaron sin secuelas y la tercera, a los seis meses del alta, presenta secuelas cognitivas. Conclusiones. Los casos descritos comenzaron con clinica psicotica aguda. La evolucion psiquiatrica atipica y la clinica neurologica alertaron de la posibilidad de una encefalitis. El reconocimiento de la enfermedad y la coordinacion entre servicios es fundamental para un diagnostico y tratamiento precoz. El analisis sistematico de liquido cefalorraquideo en pacientes con un primer episodio psicotico agudo-subagudo contribuiria a adelantar el diagnostico. En mujeres jovenes hay que buscar siempre un teratoma ovarico u otro tumor asociado.