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Frequency and characteristics of isolated psychiatric episodes in anti–N-methyl-d-aspartate receptor encephalitis.
JAMA Neurol. 2013 Sep 01; 70(9):1133-9.JN

Abstract

IMPORTANCE

Patients with anti–N-methyl-D-aspartate receptor (NMDAR) encephalitis often develop prominent psychiatric manifestations. The frequency and type of isolated psychiatric episodes (pure psychiatric symptoms without neurological involvement) either as initial presentation of the disease or as relapse are unknown.

OBJECTIVE

To determine the frequency, symptoms, and outcome of isolated psychiatric episodes in a cohort of patients with anti-NMDAR encephalitis.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort of patients diagnosed during a5-year period (median follow-up, 2 years). A total of 571 patients with IgG antibodies against the NR1 subunit of the NMDAR were included in the study. Antibody studies were performed at the University of Pennsylvania and the University of Barcelona, and clinical information was obtained by us or referring physicians.

MAIN OUTCOMES AND MEASURES

Frequency, type of symptoms, and outcome of patients with anti-NMDAR encephalitis and isolated psychiatric manifestations.

RESULTS

Of 571 patients, 23 (4%) developed isolated psychiatric episodes, 5 at disease onset and 18 during relapse. For all 23 patients, age (median, 20 years), sex (91%female), and tumor association (43%; ovarian teratoma in all cases) were similar to the population at large.Predominant symptoms included delusional thinking (74%), mood disturbances (70%,usually manic), and aggression (57%). Brain magnetic resonance imaging findings were abnormal in 10 of 22 patients (45%) and cerebrospinal fluid analysis showed pleocytosis in 17 of 22 patients (77%). Eighty-three percent of the patients had full or substantial recovery after immunotherapy and tumor resection when appropriate. After relapse, 17 of 18 patients(94%) returned to a similar or better prerelapse functional level.

CONCLUSIONS AND RELEVANCE

Isolated psychiatric episodes are rare but can occur as initial onset or relapse of anti-NMDAR encephalitis. Recognition of these episodes is important because they respond to immunotherapy. In patients with new-onset psychosis, having a history of encephalitis, subtle neurological symptoms, and/or abnormal results on ancillary tests should prompt screening for NMDAR antibodies.

Authors

No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23877059

Citation

Kayser, Matthew S., et al. "Frequency and Characteristics of Isolated Psychiatric Episodes in anti–N-methyl-d-aspartate Receptor Encephalitis." JAMA Neurology, vol. 70, no. 9, 2013, pp. 1133-9.
Kayser MS, Titulaer MJ, Gresa-Arribas N, et al. Frequency and characteristics of isolated psychiatric episodes in anti–N-methyl-d-aspartate receptor encephalitis. JAMA Neurol. 2013;70(9):1133-9.
Kayser, M. S., Titulaer, M. J., Gresa-Arribas, N., & Dalmau, J. (2013). Frequency and characteristics of isolated psychiatric episodes in anti–N-methyl-d-aspartate receptor encephalitis. JAMA Neurology, 70(9), 1133-9.
Kayser MS, et al. Frequency and Characteristics of Isolated Psychiatric Episodes in anti–N-methyl-d-aspartate Receptor Encephalitis. JAMA Neurol. 2013 Sep 1;70(9):1133-9. PubMed PMID: 23877059.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Frequency and characteristics of isolated psychiatric episodes in anti–N-methyl-d-aspartate receptor encephalitis. AU - Kayser,Matthew S, AU - Titulaer,Maarten J, AU - Gresa-Arribas,Núria, AU - Dalmau,Josep, PY - 2013/7/24/entrez PY - 2013/7/24/pubmed PY - 2013/11/14/medline SP - 1133 EP - 9 JF - JAMA neurology JO - JAMA Neurol VL - 70 IS - 9 N2 - IMPORTANCE: Patients with anti–N-methyl-D-aspartate receptor (NMDAR) encephalitis often develop prominent psychiatric manifestations. The frequency and type of isolated psychiatric episodes (pure psychiatric symptoms without neurological involvement) either as initial presentation of the disease or as relapse are unknown. OBJECTIVE: To determine the frequency, symptoms, and outcome of isolated psychiatric episodes in a cohort of patients with anti-NMDAR encephalitis. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort of patients diagnosed during a5-year period (median follow-up, 2 years). A total of 571 patients with IgG antibodies against the NR1 subunit of the NMDAR were included in the study. Antibody studies were performed at the University of Pennsylvania and the University of Barcelona, and clinical information was obtained by us or referring physicians. MAIN OUTCOMES AND MEASURES: Frequency, type of symptoms, and outcome of patients with anti-NMDAR encephalitis and isolated psychiatric manifestations. RESULTS: Of 571 patients, 23 (4%) developed isolated psychiatric episodes, 5 at disease onset and 18 during relapse. For all 23 patients, age (median, 20 years), sex (91%female), and tumor association (43%; ovarian teratoma in all cases) were similar to the population at large.Predominant symptoms included delusional thinking (74%), mood disturbances (70%,usually manic), and aggression (57%). Brain magnetic resonance imaging findings were abnormal in 10 of 22 patients (45%) and cerebrospinal fluid analysis showed pleocytosis in 17 of 22 patients (77%). Eighty-three percent of the patients had full or substantial recovery after immunotherapy and tumor resection when appropriate. After relapse, 17 of 18 patients(94%) returned to a similar or better prerelapse functional level. CONCLUSIONS AND RELEVANCE: Isolated psychiatric episodes are rare but can occur as initial onset or relapse of anti-NMDAR encephalitis. Recognition of these episodes is important because they respond to immunotherapy. In patients with new-onset psychosis, having a history of encephalitis, subtle neurological symptoms, and/or abnormal results on ancillary tests should prompt screening for NMDAR antibodies. SN - 2168-6157 UR - https://www.unboundmedicine.com/medline/citation/23877059/Frequency_and_characteristics_of_isolated_psychiatric_episodes_in_anti–N_methyl_d_aspartate_receptor_encephalitis_ L2 - https://jamanetwork.com/journals/jamaneurology/fullarticle/10.1001/jamaneurol.2013.3216 DB - PRIME DP - Unbound Medicine ER -