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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

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. 



Work-up
  • 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


Treatment
  • 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. 




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     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic






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