Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Neuropsychiatric and Multidisciplinary Approach to a Patient Not Responding to First-Line Treatment

The understanding of anti-NMDA (N-methyl-D-aspartate) receptor encephalitis, recognized by Dalmau and colleagues in 2007, has come a long way in helping clinicians to recognize the significance of rapidly progressive psychiatric symptoms in patients who are actually suffering from autoimmune disease. This subtype of autoimmune encephalitis manifests from antibodies that target the NR1 and/or NR2 subunits of NMDA receptors in serum or cerebrospinal fluid. Since gaining notoriety among neurologists, it has shown an etiologic predilection for children, adolescents, and young adult females, often associated with ovarian teratomas. Conversely, it affects young males as well, though it is rarer to find co-occurring tumors. It is a multistage disorder, initially presenting with psychiatric symptoms that progress in varying fashion, including headache, fever, nuchal rigidity, emesis, seizure, autonomic instability, auditory and visual hallucinations, delusional ideation, agitation, altered sensorium, and motor disturbances (i.e. dyskinesia, catatonia, etc.). Early diagnosis is critical due to the relatively high (25%) mortality rate. In this case, we present the case of a 30-year-old male who presented to our institution's Comprehensive Psychiatric Emergency Program (CPEP) exhibiting bizarre behavior and visual hallucinations, and was later confirmed to have anti-NMDA receptor encephalitis. The case report highlights the risk factors, disease course, and treatment modalities of anti-NMDA receptor encephalitis with special emphasis on the subsect of patients who may not respond to first-line therapies.