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Autoimmune Encephalitis in Long-Standing Schizophrenia: A Case Report

Provisionally accepted
The final version of the article will be published here soon pending final quality checks
 Amy Vaux1*, Karen Robinson1,  Burcu Saglam1, Nathan Cheuk1, Trevor Kilpatrick1, 2,  Andrew Evans1 and Mastura Monif1, 3
  • 1Royal Melbourne Hospital, Australia
  • 2Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia
  • 3Department of Neuroscience, Central Clinical School, Monash University, Australia

Anti-NMDA Antibody (Ab) mediated encephalitis is an autoimmune disorder involving the production of antibodies against NMDA receptors (NMDAR; N-Methyl-D-aspartate receptors) in the central nervous system (CNS) that leads to neurological or psychiatric dysfunction. Initially described as a paraneoplastic syndrome in young women with teratomas, increased testing has found it to be a heterogeneous condition that affects both sexes with varying clinical manifestations, severity, and aetiology.
This case report describes a 67-year-old man with a 40-year history of relapsing, severe, treatment-refractory schizoaffective disorder. Due to worsening of his condition during a prolonged inpatient admission for presumed relapse of psychosis, a revisit of the original diagnosis was considered with extensive investigations performed including an autoimmune panel. This revealed anti-NMDAR antibodies in both serum and cerebrospinal fluid (CSF) on two occasions. Following treatment with intravenous immunoglobulin (IVIg) and methylprednisolone, he demonstrated rapid symptom improvement.
This is a rare case of a longstanding psychiatric presentation with a pre-existing diagnosis of schizoaffective disorder subsequently found to have anti NMDA Ab mediated encephalitis. Whether the case is one of initial NMDA encephalitis versus overlap syndrome is unknown. Most importantly this case highlights the need for vigilance and balanced consideration for treatment in cases of longstanding psychiatric presentation where the case remains treatment refractory to antipsychotics, or when atypical features including seizures, and autonomic dysfunction or focal neurology, are observed.

Keywords: autoimmune encephalitis, NMDA encephalitis, Chronic schizophrenia, Diagnostic dilemma, Neuropsychaitric disorders, case report, NMDA antibody

Received: 08 Nov 2021; Accepted: 27 Dec 2021.

Copyright: © 2021 Vaux, Robinson, Saglam, Cheuk, Kilpatrick, Evans and Monif. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Amy Vaux, Royal Melbourne Hospital, Melbourne, Australia