It's in the Receptors: A Rare Cause of Fever and Psychosis

SESSION TITLE: Nervous System Disorders in the ICU 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute mental status changes with fever present a challenging medical emergency. Other than common infectious causes, a number of autoimmune and metabolic etiologies should be considered in the differential. Psychotic features can be a clue to underlying diagnosis. We present a rare case of psychosis and fever progressing rapidly into coma that was successfully diagnosed and treated. CASE PRESENTATION: A 59 year old female with no significant past medical history presented to the emergency room (ER) with mental status changes, confusion and psychotic behavior. Three days prior to admission she had headaches and fevers, and the night prior she was displaying suicidal behavior. In the ER the patient was afebrile but with heart rate up to 130’s and SBP in 160’s. She was initially very agitated and had to be restrained. Physical exam revealed no focal neurological deficits. Her evaluation included a normal head CT and a laboratory work-up demonstrating mild elevation in LFT’s. She became more encephalopathic and a lumbar puncture was obtained demonstrating a lymphocytic pleocytosis . An MRI with and without contrast was normal. An EEG revealed mild slowing but no epileptiform discharges. She was started on acyclovir for possible encephalitis, however CSF studies remained negative. She developed episodes of severe autonomic instability requiring transfer to the intensive care unit. Further CSF studies were performed, returning positive for NMDA-receptor antibodies. She was started on intravenous immunoglobulin and solumedrol 1g daily for 5 days. A CT chest/abd/pelvis with IV contrast and pelvic ultrasound were performed to screen for occult malignancy and were normal. She developed worsening encephalopathy with rigidity and continuing hemodynamic instability. She then underwent plasmapheresis which was unsuccessful. Rituximab was initiated for 4 doses and IV magnesium was administered for her rigidity. One week afterwards, she started showing signs of improvement with attempts to move her extremities and eventually regaining the ability to have a conversation. DISCUSSION: Anti-NMDA receptor encephalitis is a rare autoimmune encephalitis. Prominent psychiatric features and autonomic instability are hallmarks of the disease. Anti-NMDA antibodies are diagnostic, and treatment options include steroids, plasmapheresis, IVIG and rituximab. CONCLUSIONS: As our case illustrates, autoimmune encephalitis should be considered in patients presenting with psychosis and autonomic instability, as these features are not commonly present in infectious or metabolic etiologies of acute encephalopathy. Reference #1: Vitaliani, Roberta, Warren Mason, Beau Ances, Theodore Zwerdling, Zhilong Jiang, and Josep Dalmau. “Paraneoplastic Encephalitis, Psychiatric Symptoms, and Hypoventilation in Ovarian Teratoma.” Annals of Neurology 58.4 (2005): 594-604. DISCLOSURE: The following authors have nothing to disclose: Jaspreet Hehar, Eva Otoupalova, Giovi Grasso-Knight No Product/Research Disclosure Information