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Chapter 6. Neurologic Infectious Diseases

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A 42-year-old woman was transferred to the intensive care unit (ICU) from the psychiatry ward for fevers, fluctuation of blood pressure, tachycardia, and a seizure. There was a concern for her ability to protect her airway, and she was intubated. Her admission note states that she was admitted due to hallucinations, disorganized thinking, catatonic features, and echolalia.

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What is the likely cause of her initial presentation?

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A. Zika virus

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B. West Nile encephalitis

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C. Anti-NMDA (N-methyl-D-aspartate) encephalitis

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D. Serotonin syndrome

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E. Malignant hyperthermia

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C. Anti-NMDA encephalitis patients may present with prodromal headache, fever, or a viral-like process, followed in a few days by a multistage progression of symptoms that include prominent psychiatric manifestations (anxiety, agitation, bizarre behavior, hallucinations, delusions, disorganized thinking); isolated psychiatric episodes may rarely occur at initial onset or at relapse. Other symptoms may also include insomnia, memory deficits, seizures, decreased level of consciousness, stupor with catatonic features, frequent dyskinesias (orofacial, choreoathetoid movements, dystonia, rigidity, opisthotonic postures), autonomic instability (hyperthermia, fluctuations of blood pressure, tachycardia, bradycardia, cardiac pauses, and sometimes hypoventilation requiring mechanical ventilation), and language dysfunction (diminished language output, mutism). Echolalia is often noted in the early stages or in the recovery phase of the disorder.

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A 42-year-old woman was transferred to the intensive care unit (ICU) from the psychiatry ward for fevers, fluctuation of blood pressure, tachycardia, and a seizure. There was a concern for her ability to protect her airway, and she was intubated. Her admission note states that she was admitted due to hallucinations, disorganized thinking, catatonic features, and echolalia.

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What is your next step in the workup of the proposed diagnosis?

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A. Serum collection for viral testing

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B. Lumbar puncture for viral testing

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C. Transvaginal ultrasound

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D. Abdominal computed tomography (CT) scan

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E. Transesophageal echocardiography

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C. Anti-NMDA encephalitis should be suspected with this clinical presentation. Transvaginal ultrasound should be done next to exclude ovarian malignancy because there is a high association between NMDA encephalitis and ovarian teratoma, but this is not necessarily present. Although the diagnosis is confirmed with detection of immunoglobulin (Ig) G antibodies to the GluN1 (also known as the NR1) subunit of the NMDA receptor in the serum or cerebrospinal fluid (CSF), there are additional common findings:

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  • CSF lymphocytic pleocytosis with or without oligoclonal bands

  • Electroencephalography (EEG) with infrequent epileptic discharges, but frequent slow, ...

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