Anti-NMDA receptor encephalitis presenting as an acute psychotic episode misdiagnosed as dissociative disorder: a case report

  • Yuichiro ShimoyamaEmail author,
  • Osamu Umegaki,
  • Tomoyuki Agui,
  • Noriko Kadono and
  • Toshiaki Minami
JA Clinical Reports20162:22

DOI: 10.1186/s40981-016-0048-3

Received: 17 June 2016

Accepted: 26 August 2016

Published: 1 September 2016

Abstract

Background

In 2005, “anti-N-methyl-d-aspartate (NMDA) receptor encephalitis,” a syndrome with prominent psychiatric symptoms, memory loss, decrease in level of consciousness, and central hypoventilation, was described in young women with ovarian teratomas and antibodies against an antigen highly expressed in the hippocampus. This report highlights the growing need for increased awareness among psychiatrists and other relevant medical professionals about this under-diagnosed disorder, which should be considered in differential diagnoses.

Case presentation

A 19-year-old female with no psychiatric history presented to a district general hospital with acute psychosis, emotional lability, memory deficit, fluctuating behavioral changes such as wandering and babbling, and seizure. She was admitted to the hospital with a provisional diagnosis of dissociative disorder. Soon after admission, she developed aspiration pneumonia and was intubated for mechanical ventilation. She was transferred to our hospital for further assessment and admitted to the intensive care unit for ventilation. Laboratory test results were unremarkable, but her EEG showed non-specific slowing with no epileptiform activity, and brain computed tomography (CT) and MRI also showed no remarkable findings. Cerebrospinal fluid (CSF) analysis showed an elevated white blood cell count (15 cells/hpf; 70 % lymphocytes), and blood serum and CSF samples tested positive for NMDA receptor antibodies. Abdominal contrast-enhanced CT revealed an ovarian teratoma, which was subsequently removed laparoscopically. Postoperative immunotherapy (steroids, intravenous immunoglobulin, and plasmapheresis) led to gradual improvement. On day 25 of hospitalization, neuropsychological assessment demonstrated that overall, she had returned to her premorbid level of functioning. Her condition substantially improved over several months of cognitive rehabilitation, and she was eventually discharged on day 75.

Conclusions

Anti-NMDA receptor encephalitis, a form of autoimmune encephalitis, is commonly associated with tumors and often misdiagnosed. Diagnosis can be confirmed by detecting NMDA receptor antibodies in the patient’s serum or CSF. Management can be achieved with immunosuppressive therapy and tumor resection.

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A Case of Conversion Catatonia Misdiagnosed for 24 Years

Pauline K. Wiener, M.D.

INTRODUCTION Catatonia is a syndrome whose etiology may be both diverse and difficult to substantiate . Ms. H. is a 45-year-old black female with 18 previous psychiatric hospitalizations beginning at age 21 . A common characteristic to all hospitalizations was a catatonic presentation (i.e ., the patient was mute with marked muscular rigidity; she would refuse to eat or follow orders). In ea ch of her previous 18 hospitalizations, the patient was thought to be psychotic. It was found that each catatonic episode could be related to a severe psychological stressor. The patient’s illness never involved delusions, hallucinations or disturbances in thought form. Upon detailed evaluation of this patient’s history she was found to have symptoms consistent wit h conversion disorder. I report here the identification of a conversion disorder presenting as recurrent episodes of catatonia. Intramuscular lorazepam was found to be repeatedly successful in resolving the ca tatonic state .

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Some cases of schizophrenia and bipolar disorder could be misdiagnosed immune disorders

Some patients sectioned with conditions such as schizophrenia or bipolar disorder could instead have a treatable immune disorder, Oxford University scientists have found.

Currently, people experiencing psychosis are often thought to be suffering from mental disorder and are treated as such with medication and psychotherapy.

But the research, published yesterday in the Lancet psychiatry journal, suggests that some of these patients could in fact be treated with immunosuppressant drugs.

Scientists studied 228 patients who had visited mental health service sites across England having experienced psychosis for the first time.

They took blood samples from each of the patients and found that three per cent of them had antibodies that attack the NMDA receptor, which allows brain cells to communicate with each other.

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Mom Misdiagnosed With Postpartum Psychosis After Childbirth When She Really Had Autoimmune Diseases and Multiple Sclerosis

My name is Kimberly and my story begins in 1978. I woke up one morning, unable to move my legs or left arm and unable to get out of bed. At the time, I was only 18 years old. I went to the hospital, was admitted for a week, and aside from my psoriasis, was discharged without a diagnosis.

As weeks went by, I continued to worsen. I developed red raised nodules on the shins of my legs. They were warm to the touch and very painful. The doctors were baffled and again sent me home without a diagnosis.

After a few weeks of horrific pain, my father carried me into a different hospital, where I was admitted with concern from the doctors there may have been fluid build-up in my ankles and I would never walk again.  Fortunately, there was no fluid. I spent a week in the hospital only to have them discharge me with a diagnosis of Sarcoidosis and Erthema nodosum. They thought it could have also been polio or rheumatic fever, and so I spent six months in a wheelchair. I was given a final diagnoses of psoriasis, sarcoidosis, Erthema nodosum, and lupus. Along with receiving steroid injections in my ankles, I took liquid painkillers just to be able to walk and function.

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Misdiagnosed bipolar: One girl’s struggle through psych wards before Stanford doctors make bold diagnosis and treatment

SAN JOSE — One day, Tessa Gallo was a typical sixth-grader, performing in school plays, running on the track team, goofing around with her two sisters and giggling with girlfriends at sleepovers.

The next, said her mother, Teresa, “She was psychotic and mentally retarded.”

In bizarre and frightening scenes, Tessa acted as frantic as a caged animal, darting out of the family car into traffic, jumping fences and hiding in neighbors’ bushes. At times she seemed catatonic, with food falling out of her mouth because she somehow couldn’t swallow. She repeated the same few sentences over and over, worried about her braces, wanting to go home.

And finally, she said nothing at all. For nine months, Tessa stopped talking. Not a word.

Doctors diagnosed her with bipolar disorder, prescribed psychiatric drugs that didn’t work and sent the San Jose family on a nightmarish odyssey through psych wards, group homes and isolation rooms.

Then, suddenly, more than 10 months into the Gallos’ terrifying ordeal, a pair of Stanford University doctors told the family that Tessa wasn’t bipolar at all. She was probably suffering from a tragically misdiagnosed condition that mimics mental illness in a way doctors are only starting to understand.

“I’ve seen cases like this before,” Dr. Jennifer Frankovich of Lucile Packard Children’s Hospital told the Gallos. “I think I can bring her back.”

Controversial diagnosis

What Frankovich, a pediatric rheumatologist, and Dr. Kiki Chang, a child psychiatrist, concluded was that Tessa likely had an infection or other trigger that caused her immune system to mistakenly attack her brain, dramatically changing Tessa’s behavior overnight. It’s a condition called PANS — pediatric acute-onset neuropsychiatric syndrome — that in some cases, if caught early enough, could be cured by commonly used antibiotics. Without early treatment, they say, children can suffer needlessly.

It would take a mother’s stubborn devotion and the conviction of two doctors willing to stake their reputation on a controversial treatment to bring Tessa back from the brink. At the same time, they believe cases like Tessa’s could help unlock the mysteries of the brain and reveal how something as common as an infection could be behind a growing number of psychological disorders.

PANS is so new and so misunderstood, that there are no reliable estimates of how many children are affected. A national PANS parent support group believes the number nationwide could be more than 150,000, or about a quarter of the children who have obsessive compulsive disorder or other tics.

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Visual hallucinations from retinal detachment misdiagnosed as psychosis.

J Psychiatr Pract. 2011 Mar;17(2):133-6. doi: 10.1097/01.pra.0000396066.79719.c5.

Abstract

Hallucinations are a common presenting symptom in schizophrenia and other psychotic disorders. In particular, auditory hallucinations, such as hearing voices, are the most common type of hallucination described in schizophrenia, while visual hallucinations are less frequently seen. Hallucinations are also present in disorders that are not primarily psychotic in nature, including mood disorders, substance-induced disorders, and psychosis due to a general medical condition. However, it is extremely important to rule out general medical causes of hallucinations, as they are often treatable and reversible, and if left untreated, the underlying non-psychiatric disorders causing them can lead to irreversible damage. We present a case in which a 48-year-old woman with schizophrenia began to complain of visual disturbances. Because of her delusional interpretation of these disturbances, they were initially attributed to psychosis, but the disturbances were in fact found to be the result of a retinal detachment.

Misdiagnosis of schizophrenia in a patient with psychotic symptoms.

 

Abstract

OBJECTIVE:

A case is presented of a 37-year-old black woman with a 5-year history of a chronic psychotic illness, diagnosed as schizophrenia, who presented to the emergency room complaining of a severe headache, while appearing confused and experiencing visual and auditory hallucinations. The purpose of this case study is to illustrate the way in which the appellation of schizophrenia can be misapplied in a patient with a complicated medical history and poor follow-up evaluation and treatment.

BACKGROUND:

Patients with active psychosis are frequently unable to provide a coherent or comprehensive medical history. In the absence of obvious indications to the contrary, a diagnosis of a primary psychiatric illness is often assumed, especially if this label has been applied in the past. However, the differential diagnosis of psychosis is extensive.

METHODS:

This patient was given a complete psychiatric and neurologic evaluation, and aspects of the history that had been lost or ignored were uncovered and reevaluated.

RESULTS:

A diagnosis other than schizophrenia was made and another treatment, other than antipsychotic drugs, was initiated. The patient responded rapidly with improved cognitive function and resolution of her psychotic symptoms.

CONCLUSIONS:

This case serves to illustrate how the absence of a careful clinical assessment and historical case review, in patients who have been previously labeled as schizophrenic, can perpetuate misdiagnoses and inappropriate treatments. It highlights the importance, especially in patients with an incomplete medical history, of ruling out all organic causes of psychosis to avoid inappropriately labeling someone as having a psychiatric illness