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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, May 8, 2017

Anti-NMDA Encephalitis

Anti-NMDA receptor encephalitis is an acute form of lethal encephalitis which has a high probability for recovery with timely diagnosis and treatment. Therefore, as frontline physicians it is important for us to be aware of this disease. 

Anti-NMDA Encephalitis is an autoimmune disease, where the primary target is NR1/NR2 subunit of the NMDA receptor (N-Methyl D-Aspartate). This disease has recently received press over the last decade but it is suspected that this entity still remains under-recognised. 

Clinical Presentation

Typically NMDA-Encephalitis starts with a flu like illness(weeks to months before) followed by personality changes, psychotic behaviour, disorientation, confusion, paranoia, dyskinesia, seizures, hallucinations and autonomic dysfunction. The condition is associated with tumours, mostly teratomas of the ovaries. Male to Female ratio is 9:1 and the typical patient is a young female. 

  • Routine Bloods (CBC, Renal, Liver, Kidney Profiles, TSH)
  • Head Imaging (SOLs, r/o other causes
  • Lumbar PunctureNR1 and NR2 antibodies in CSF
  • Pelvic ultrasound (to look for teratomas)

Differential Diagnosis
  • Psychiatric Illnesses 
  • Substance Abuse
  • Other forms of Viral Encephalitis
  • Limbic System Encephalitis

  • Pelvic Tumor Removal
  • Immunotherapy - corticosteroids, intravenous immunoglobulin and plasmapheresis
  • Rehabilitation 

The recovery process usually takes several months and paradoxically, the symptoms can reappear but as the recovery process continues, the psychosis eventually fades away. 

Take Home:
It is important to consider anti-NMDA receptor encephalitis as a possible cause of acute psychosis in young patients with no past neuropsychiatric history before we label it as a "Mental Health" problem. 

Posted by:

     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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