Panic Attacks and Delusions in a 17 Year Old Girl - Psychiatric or Neurologic?

Background: Anti-N-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis is the most common autoimmune encephalitis in childhood. Nevertheless, diagnosis is often delayed.

Case Report: A 17 year old girl was admitted to a psychiatric hospital for rapidly increasing panic attacks and delusions. Schizophrenia was suspected and neuroleptics and benzodiazepines were given. Despite the treatment, she developed severe catatonia, tremor and mutism. She got incontinent, showed increased sweating and dysphagia. In suspicion of malignant neuroleptic syndrome, neuroleptics were withdrawn and biperiden was started. After this, her condition even worsened. She showed status epilepticus two times which was stopped with benzodiazepines. Anticonvulsive treatment was initiated with levetiracetam. Cerebral MRI was normal. EEG showed a generalised slowing without epileptiform discharges. Protein was slightly elevated in cerebrospinal fluid without pleocytosis. Bacteriological and virological tests were negative. Measurement of central nervous system (CNS)-autoantibodies showed positive results for anti-NMDAR-antibodies in serum and cerebrospinal fluid. Eight weeks after symptom onset, an immunotherapy with steroids and intravenous immunoglobulin was started and maintained for five days. Several days after initiating the therapy, her condition improved. After four weeks she could be transferred to a neurorehabilitation center. Steroids were tapered within three months. Intravenous immunoglobulin is still given every four to six weeks. Anticonvulsive therapy could be stopped after five months. EEG was normal. Six months after diagnosis, she recovered completely.

Conclusion: Anti-NMDAR encephalitis is diagnosed increasingly even in childhood and adolescence. Due to immunotherapy, completely recovery is seen in many patients. Standardized recommendations regarding implementation and duration of therapy are still missing.

No conflict of interest has been declared by the author(s).