Anti-NMDA Receptor Encephalitis Associated with Testicular Teratoma in a Patient with Long-Standing Schizophrenia
Cara Cavarretta1, Anup Sonti2, Pravesh Saini2, Nuriel Moghavem2, Masoud Majed2, Rumyar Ardakani2
1Keck School of Medicine of USC, 2USC/Los Angeles General Medical Center
Objective:
To report a case of anti-NMDA receptor encephalitis in a patient with chronic schizophrenia.
Background:
Anti-NMDA receptor encephalitis is the most common cause of autoimmune encephalitis and often presents with prominent neuropsychiatric symptoms that may mimic a primary psychiatric disorder. The diagnosis of autoimmune encephalitis may be particularly challenging in patients who have an underlying primary psychiatric disorder such as schizophrenia.
Results:
A 52 year-old male with a 30 year history of stable schizophrenia presented with subacute onset of worsening auditory and visual hallucinations, emotional lability, mania, and hyper-religiosity over the course of one week despite no recent change in anti-psychotic medications. Given his psychiatric history, his decompensation was initially attributed to his underlying schizophrenia. However, further work-up revealed the presence of a testicular mass concerning for malignancy, prompting orchiectomy and diagnostic evaluation for a paraneoplastic encephalitis. CT of the head was unremarkable. MRI of the brain was not obtained due to the presence of retained bullet fragments. CSF analysis revealed normal cell count, protein, glucose, and infectious workup. EEG revealed abundant right temporal lobe epileptiform discharges. Given the subacute onset of worsening neuropsychiatric symptoms in the setting of a suspected malignancy and focal epileptiform discharges, empiric treatment for autoimmune encephalitis was initiated with high-dose steroids and intravenous immunoglobulin. Ultimately, autoantibody testing returned positive for NMDA receptor antibodies by cell-based assay in both serum (>1:160 titer) and CSF (1:80 titer). Histological analysis of the testicular mass was consistent with post-pubertal testicular teratoma.
Conclusions:
Anti-NMDA receptor encephalitis may develop in patients with primary psychiatric disorders and a high index of suspicion should be maintained if the clinical presentation and ancillary testing is compatible with autoimmune encephalitis. Our case also highlights the rare association between testicular teratoma and NMDA receptor encephalitis.
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