Missing Piece of Puzzle: Electro-Convulsive Therapy (ECT) in Patients with anti-NMDA Receptor Encephalitis
Objective:
To emphasize the importance of early clinical recognition of catatonia and implementation of ECT as adjuvant therapy in patients with anti-NMDAR encephalitis.
Background:
Catatonia is a symptom of anti-NMDAR encephalitis which can evolve rapidly into malignant catatonia with autonomic instability and increased morbidity. Although early immunomodulatory therapy is important to treat the underlying autoimmune disorder, resistant catatonia may require adjuvant management with ECT.
Design/Methods:
Not applicable.
Results:
We describe the cases of three females aged 23.7 ± 2.5, who were diagnosed with anti-NMDAR encephalitis. They presented with neuropsychiatric symptoms and were promptly and empirically treated with IV solumedrol with oral prednisone taper, IVIG, +/- plasma exchange (case 3), preceding diagnostic confirmation via CSF NMDA antibody positivity. Ovarian teratomas were detected in all cases and resected shortly after hospitalization. Additionally, cases 1 and 2 received Rituximab while hospitalized, and cases 2 and 3 received anti-seizure medications for temporal onset seizures. In spite of this, all required escalating large doses of benzodiazepines, in conjunction with amantadine and bromocriptine, for refractory malignant catatonia with dysautonomia. ECT treatments were thus initiated (once to twice daily for first week, followed by three times weekly) with bilateral electrode placement. All cases tolerated ECT treatments well and were gradually noted to have marked clinical improvement as was measured by the Bush-Francis Catatonia Rating Scale (BFCRS) (initial assessment: 27.6 ± 8.3; last assessment 1.3 ± 1.5).
Conclusions:
This case series supports the growing body of evidence emphasizing the importance of clinical recognition of catatonia among patients with suspected or confirmed anti-NMDAR encephalitis, and the early implementation of ECT into treatment algorithms. The use of standardized assessment tools such as the BFCRS and cognitive impairment screening scales should be considered for monitoring of symptom response and tolerability.