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Occult teratoma in a case of N-methyl-D-aspartate receptor encephalitis.
Neuroradiol J. 2018 Aug; 31(4):415-419.NJ

Abstract

N-methyl-D-aspartate receptor encephalitis (NMDARe) is one of 13 autoimmune-mediated encephalitides that have been discovered over the last decade. This case report describes the course of a 26-year-old female who presented with new-onset seizures and insomnia, complicated by encephalitis. The initial workup ruled out common causes of encephalitis, while a transvaginal ultrasound (TVUS), and computed tomography (CT) scans of the chest, abdomen, and pelvis did not identify a mass. Based on the suspicion that she may have autoimmune encephalitis, the patient was treated with intravenous immunoglobulins and plasma exchange, but continued to deteriorate. Whole-body positron emission tomography (PET) scan identified a small hypermetabolic pelvic mass. Shortly thereafter serum and cerebral spinal fluid NMDAR antibody titers were reported as positive, prompting repetition of the TVUS, which confirmed the presence of an ovarian teratoma. The patient had a laparoscopic oophorectomy with subsequent resolution of her symptoms, further confirming the diagnosis. Despite the sensitivities of TVUS and CT of up to 94% and 98%, respectively, the teratoma was unusually small, necessitating the addition of a PET scan to identify the lesion. These neoplasms are thought to have low uptake on PET; however, it is possible that focal inflammation may have enhanced the detection. It is unlikely that the teratoma grew during hospitalization as the average growth rate is 1.8 mm per year. Regardless, the lesson that can be learned is that imaging modalities beyond CT and TVUS, such as PET, can be helpful, as identification of a resectable tumor may alter management and ultimately improve outcomes.

Authors+Show Affiliations

1 Division of Academic Internal Medicine and Geriatrics, University of Illinois, Chicago IL USA.2 Department of Neurology, The University of Chicago, Chicago IL USA.3 Ross University School of Medicine, Portsmouth, Dominica.4 Department of Neurology and Rehabilitation, University of Illinois, Chicago IL USA.5 Department of Pathology, The University of Chicago, Chicago IL USA.6 Department of Internal Medicine, Mount Sinai Hospital, Chicago IL USA.7 Illinois School of Professional Psychology at Argosy University, Chicago IL USA.5 Department of Pathology, The University of Chicago, Chicago IL USA.

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

29513076

Citation

Lwanga, Anita, et al. "Occult Teratoma in a Case of N-methyl-D-aspartate Receptor Encephalitis." The Neuroradiology Journal, vol. 31, no. 4, 2018, pp. 415-419.
Lwanga A, Kamson DO, Wilkins TE, et al. Occult teratoma in a case of N-methyl-D-aspartate receptor encephalitis. Neuroradiol J. 2018;31(4):415-419.
Lwanga, A., Kamson, D. O., Wilkins, T. E., Sharma, V., Schulte, J. J., Miller, J., Hassan, I., & Lastra, R. R. (2018). Occult teratoma in a case of N-methyl-D-aspartate receptor encephalitis. The Neuroradiology Journal, 31(4), 415-419. https://doi.org/10.1177/1971400918763578
Lwanga A, et al. Occult Teratoma in a Case of N-methyl-D-aspartate Receptor Encephalitis. Neuroradiol J. 2018;31(4):415-419. PubMed PMID: 29513076.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Occult teratoma in a case of N-methyl-D-aspartate receptor encephalitis. AU - Lwanga,Anita, AU - Kamson,David O, AU - Wilkins,Tiffany E, AU - Sharma,Vinny, AU - Schulte,Jefree J, AU - Miller,James, AU - Hassan,Ikram, AU - Lastra,Ricardo R, Y1 - 2018/03/07/ PY - 2018/3/8/pubmed PY - 2018/10/12/medline PY - 2018/3/8/entrez KW - NMDA receptor KW - PET KW - Seizures KW - encephalitis KW - psychosis KW - teratoma SP - 415 EP - 419 JF - The neuroradiology journal JO - Neuroradiol J VL - 31 IS - 4 N2 - N-methyl-D-aspartate receptor encephalitis (NMDARe) is one of 13 autoimmune-mediated encephalitides that have been discovered over the last decade. This case report describes the course of a 26-year-old female who presented with new-onset seizures and insomnia, complicated by encephalitis. The initial workup ruled out common causes of encephalitis, while a transvaginal ultrasound (TVUS), and computed tomography (CT) scans of the chest, abdomen, and pelvis did not identify a mass. Based on the suspicion that she may have autoimmune encephalitis, the patient was treated with intravenous immunoglobulins and plasma exchange, but continued to deteriorate. Whole-body positron emission tomography (PET) scan identified a small hypermetabolic pelvic mass. Shortly thereafter serum and cerebral spinal fluid NMDAR antibody titers were reported as positive, prompting repetition of the TVUS, which confirmed the presence of an ovarian teratoma. The patient had a laparoscopic oophorectomy with subsequent resolution of her symptoms, further confirming the diagnosis. Despite the sensitivities of TVUS and CT of up to 94% and 98%, respectively, the teratoma was unusually small, necessitating the addition of a PET scan to identify the lesion. These neoplasms are thought to have low uptake on PET; however, it is possible that focal inflammation may have enhanced the detection. It is unlikely that the teratoma grew during hospitalization as the average growth rate is 1.8 mm per year. Regardless, the lesson that can be learned is that imaging modalities beyond CT and TVUS, such as PET, can be helpful, as identification of a resectable tumor may alter management and ultimately improve outcomes. SN - 2385-1996 UR - https://www.unboundmedicine.com/medline/citation/29513076/Occult_teratoma_in_a_case_of_N_methyl_D_aspartate_receptor_encephalitis_ L2 - https://journals.sagepub.com/doi/10.1177/1971400918763578?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -