Aggressive Agitation Management Affecting Acute Rehabilitation Course in NMDA Receptor Encephalitis: A Case Report and Suggestion for Management-Aggressive Agitation Management Affecting Acute Rehabilitation Course in NMDA Receptor Encephalitis: A Case Report and Suggestion for Management

Video Transcription

This is a case report about an 18-year-old male with a known diagnosis of NMDA receptor encephalitis that was treated with rituximab two months prior to this presentation.  He was admitted from an LTAC due to disinhibition, aggression, and agitation. On admission, he was thought to be sympathetic storming and was started on oxycodone and  his anti-epileptic medications, Keppra, Vempat, and Depakote, were adjusted. He was admitted to rehabilitation, however, these episodes of aggression and disinhibition  continued which halted his rehab course as he was uncooperative with staff and family. With the help and consultation of neurology, it was realized that the patient was experiencing  psychosis due to chronic NMDA receptor encephalitis rather than sympathetic storming. He was started on Seroquel and slowly weaned off of his oxycodone and Keppra as these were  thought to be contributing to his aggression. He was placed on propanolol and gabapentin in place of these.  He became less aggressive and more cooperative and was eventually discharged at a modified independent to independent level for gait and all ADLs from a max to modest level on  admission. As an outpatient, his anti-epileptics were further weaned and adjusted based on his symptoms as reported by his mother.  He was also weaned off of Seroquel and taken off of his propanolol. On continued follow-ups, the patient was reported to be less aggressive and began playing sports  he enjoyed such as golf, baseball, and bowling. He began to help his father with his car dealership and even returned to college to possibly pursue finance.  The patient is still figuring out what he wants to do. This presentation is rare, but chronic NMDA receptor encephalitis can result in relapses  of psychosis involving disinhibition, personality changes, and impulsivity months to years after the initial symptoms and diagnosis.  Psychosis normally occurs acutely in the clinical course and patients return to baseline and improves with treatment of encephalitis, but this can still occur.  If realized and treated aggressively as this patient was, it can lead to improved clinical outcomes such as this patient's return to sports and helping his family.  It can also lead to, especially in this patient's case, improved rehabilitation course and return to patient's baseline function. Thank you for your time.

Video Summary

This case report discusses the rare occurrence of chronic NMDA receptor encephalitis leading to relapses of psychosis, which manifested as disinhibition and aggression in an 18-year-old male. Initially misdiagnosed as sympathetic storming, it was later determined that the patient was experiencing psychosis related to the encephalitis. Treatment involved adjusting medications and starting Seroquel, resulting in improvements in the patient's behavior and cooperation. With continued follow-ups and medication adjustments, the patient showed significant improvement and was able to return to sports, help his family, and consider pursuing higher education. Early recognition and aggressive treatment of psychosis in chronic NMDA receptor encephalitis can lead to positive outcomes and a return to baseline function.

Keywords

chronic NMDA receptor encephalitis

relapses of psychosis

disinhibition and aggression

Seroquel

positive outcomes