PSYCHIATRIC SYMPTOM IN ANTI N-METHYL D-ASPARTATE RECEPTOR (NMDAR) ENCEPHALITIS, HOW TO ASSES?
Authors: Aini *Syarifah , Prananjaya Bintang Arroyantri , Suryani Puji Rizky , Ikhsan Diyaz Syauki 
Published: February 2025

Abstract

Background
Anti-NMDAR Encephalitis is an autoimmune disorder with neuropsychiatric manifestations that happened rarely. In some cases, the initial symptoms is just psychiatric that worsened with or without neurological.

Method
Female, 17 years old, was taken to the emergency due to decreased consciousness. Consciousness (GCS) was 9/15, with pinpoint pupils, heart rate 160 bpm, and blood pressure less than 100mmHg. From the blood examination, the increasing of ureum and creatinine were also found, accompanied by thrombocytopenia. She was taken to psychiatrist since 2 weeks ago with psychotic complaints, feeling sad and afraid of not passing the exam, auditory hallucinations, obsessive and intrusive thoughts and also delusions, which occurred with an abrupt onset (in 3 days). Because these changes of behavior was preceded by flu-like symptoms and gastrointestinal, without the previous psychiatric history, she was also consulted to neurologist. After the CT scan and blood examination performed, all results were within normal limits, she was treated with antipsychotics (Olanzapine 5mg daily) as for acute and transient psychosis and was stopped 3 days ago due to her fever. Based on the sudden worsening of the disorder, she was currently suspected of having anti NMDAR Encephalitis complicated with acute kidney failure.

Discussion
Encephalitis is an acute brain inflammation caused by an infection, autoimmune disease, tumor, or idiopathic causes.1,2 Anti-NMDAR Encephalitis is a rare though most common autoimmune limbic encephalitis disorder.1,2 The most common prevalence is female (4:1), age varied from 25-35, with or without neoplastic lesions.1,2,3 Common neurological symptoms include seizures, headaches, fever, movement disorders, sensitivity to light and voice, stiffness, paralysis in the arms and limbs, and disturbances in consciousness.3-6 Psychiatric symptoms include hallucinations, delusions, mutism, bizarre behavior, agitation, fear, insomnia, anxiety, confusion, and short-term memory loss. 3-6 This wide and varied range of symptoms presents a challenge to diagnose and treatment. The initial phase are dominated by psychiatric symptoms preceded by a prodromal that mimicking viral infection.1,2 In the case above, the patient was taken to a psychiatrist with sudden changes in behavior dominated by thought process disturbances. The psychiatric complaints also preceded by flu-like and gastrointestinal symptoms. Although data on the frequency of psychiatric symptoms remains limited, it is agreed that psychiatric symptoms are most often present. As a result, like in this case, patients seek out psychiatrists help first. Some studies indicate that about 80%–100% of patients show psychiatric symptoms in the initial phase, and 60%–80% of patients are prescribed medication by psychiatrist without further examination, resulting in misdiagnosis and inadequate therapy.7-9 Contrast to that, some patients are intolerant to antipsychotic, and can develop fever, muscle rigidity, or coma that worsened along with the neurological symptoms.2,10-12Furthermore, the limitation of healthcare facilities and social determinants in the community, such as information on healthcare services, income, and access to healthcare also a challenge that needs to be evaluated.10-12

Conclusion
A thorough examinations are fully needed to diagnose anti-NMDAR Encephalitis to prevent further comorbidities and complications.

References
1.Ford B, McDonald A, Srinivasan S. Anti-NMDA Receptor Encephalitis: a case study and illness overview. Drugs in Context 2019; 8: 212589. DOI:10.7573/dic.212589
2.Samanta Debopam, Forshing Lui. Anti NMDAR Encephalitis. Stat Pearls, NCBI Bookshelf 2023;
3.Jan Dalmau J, Armangué T, Planagumà J, Radosevic M, Mannara F, Leypoldt F, Geis C, Lancaster E, Titulaer MJ, Rosenfeld MR, Graus F. An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol. 2019 Nov;18(11):1045-1057. - PubMed
4.Nguyen Linda, Wang Cynthia. Anti NMDA Receptor Autoimmune Encephalitis: Diagnosis and Management Strategies. International Journal of General Medicine2023:16 7-21’
5.Barry H, Byrne S, Barrett E, Murphy KC, Cotter DR. Anti-N-methyl-d-aspartate receptor encephalitis: review of clinical presentation, diagnosis and treatment. BJPsych Bull. 2015 Feb;39(1):19-23. doi: 10.1192/pb.bp.113.045518. PMID: 26191419; PMCID: PMC4495821.
6.Steeman, A., Andriescu, I., Sporcq, C. et al.Case report of anti-NMDA receptor encephalitis in a 24- year-old female: an uncommon presentation. Egypt J Neurol Psychiatry Neurosurg 58, 79 (2022). https://doi.org/10.1186/s41983-022-00512-7
7.Wang Wei, Zhang Le, Chi Xiao-Sa, et al. Psychiatric Symptoms of Patients with Anti NMDA Receptor Encephalitis. Frontier in Neurology 2019: 10. https://doi.org/10.3389/fneur.2019.01330
8.Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol.(2011) 10:63–74. doi: 10.1016/S1474-4422(10)70253-2
9.Dalmau J, Gleichman AJ, Hughes EG, Rossi JE, Peng X, Lai M, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol. (2008) 7:1091–8. doi: 10.1016/S1474-4422(08)70224-2
10.Dalmau J, Gleichman AJ, Hughes EG, Rossi JE, Peng X, Lai M, Dessain SK, Rosenfeld MR, Balice-Gordon R, Lynch DR. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol. 2008 Dec;7(12):1091-8. - PMC - PubMed
11.Lim JA, Lee ST, Jung KH, et al. Anti-N-methyl-d-aspartate receptor encephalitis in Korea: clinical features, treatment, and outcome. J Clin Neurol. 2014;10(2):157–161. doi: 10.3988/jcn.2014.10.2.157. - DOI - PMC - PubMed
12.Yadav B, Chaurasia D, Kharel A, Dhungana K. Anti-N-methyl-D-aspartate Receptor Autoimmune Encephalitis: A Case Report. JNMA J Nepal Med Assoc. 2022 Nov 2;60(255):962-964. doi: 10.31729/jnma.7307. PMID: 36705182; PMCID: PMC9795094.