Anti-NMDA-receptor encephalitis in Filipino adults: Case series and outcomes in a tertiary government hospital in the Philippines

INTRODUCTION@#We performed a case series of all five (5) confirmed adult Filipino cases of Anti-N-Methyl-D-Aspartate receptor (anti-NMDA-R) encephalitis in a tertiary government hospital in the Philippines admitted in the past three years. Two cases were identified with unique features: (1) a 23-year old female who presented with combined refractory seizures and persistent chorea and orofacial dyskinesias; and (2) a 22-year old male who presented with refractory epilepsia partialis continuua. The rest of the patients were hereby presented.@*BACKGROUND@#In the past years, anti-NMDA-R encephalitis has been considered a diagnosis of exclusion in lieu of other infectious causes of encephalitis. It is rare and an emerging disease with an incidence estimated at approximately 2-3 cases per million. Recent literature recorded severe cases of anti-NMDA-R encephalitis that presented as intractable first onset seizures, combined with hyperkinetic movement disorders, acute psychosis without a premorbid condition, and dysautonomia. @*OBJECTIVES@#To present the clinicodemographic profile and to discuss the management and outcomes of patients with anti-NMDAR encephalitis in a tertiary hospital in the Philippines.@*RESULTS@#Here, we report five confirmed cases of anti-NMDA-R encephalitis admitted in 2019-2021. The mean age is 23 years old, with 4:1 female to male ratio with a median length of hospitalization of 58 days. All patients presented with acute psychiatric symptoms without premorbid condition, focal and generalized seizures, decreased consciousness, dyskinesias, and autonomic instability. Four patients needed airway support for central hypoventilation, one had first onset seizure that developed into refractory epilepsia partialis continuua, one had persistent chorea and orofacial dyskinesia. Imaging studies of the brain included contrast-enhanced CT Scan and MRI with unremarkable findings. No female patients had an ovarian teratoma as revealed in the whole abdominal ultrasound. All CSF analysis for anti-NMDA-receptor was done in the same laboratory outside the hospital which revealed positive for NMDA-receptor antibodies, while CSF lymphocytic pleocytosis was only seen in 1/5 and protein elevation in 4/5. All of the patients underwent electroencephalogram (EEG) studies which revealed diffuse delta-theta slowing without epileptiform discharges. The patient who had persistent chorea and orofacial dyskinesias showed extreme delta brush, while one had normal EEG findings. They all received high-dose steroid and intravenous Immunoglobulin (IVIg); three patients were able to undergo Rituximab infusion. Only one female patient had mild deficits, one female was discharged fully functional and ambulatory from being weaned off from the mechanical ventilator, one female had aborted cardiac arrest and was discharged bedridden at GCS 10, and two died due to the other concomitant medical conditions. The Modified Rankin Scale (MRS) and Mini-mental Status Examination (MMSE) were used to assess the neurological and functional outcomes of our patients. @*CONCLUSION@#Anti-NMDA-R encephalitis is an emerging neurological disorder that warrants early identification as it impacts timeliness of management and long-term outcomes.

Typhoid fever presenting as acute psychosis in a young adult: case report and literature review of typhoid psychosis

@#The rarity of acute psychosis in typhoid fever can result in delayed and misdiagnosis of the condition. We report a case of a 20-year-old man who presented with fever and acute psychotic symptoms. This was associated with headache, dizziness, and body weakness. There were no other significant symptoms. Neurological examination revealed reduced muscle tone of bilateral lower limbs but otherwise unremarkable. The computed tomography (CT) scan of his brain showed no abnormality. Blood specimens for microbiological culture grew Salmonella Typhi. This isolate was susceptible to chloramphenicol, ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. He was treated with intravenous ceftriaxone for one week and responded well. He was discharged with oral ciprofloxacin for another week. The repeated blood and stool for bacterial culture yielded no growth of Salmonella Typhi.

Parte III: las locuras histéricas / Part III: the hysterical follies

Caso Clínico Paciente María R.A., 28 años, Escolaridad básica en programa diferencial, dueña de casa, Casada, 9 años de matrimonio. Su pareja tiene 62 años. Actualmente vive con esposo e hijo de 2 años, en Maipú. Durante 2016, María consultó en distintos servicios de urgencia, recibiendo distintos diagnósticos: Conversión, Síndrome conversivo. Se ingresa en Urgencia con diagnóstico: Síndrome Psicótico lúcido. Paciente en cama, sin movimientos espontáneos, con rigidez, mirada fija, deshidratada, no acepta alimentarse, negativista, no establece contacto visual, no responde preguntas simples, sin embargo, en forma espontánea puede permanecer hablando, dando cuenta de contenidos delirantes. El día de su ingreso a sector se inició terapia Electro convulsiva, y completó 5 sesiones. Tras la primera sesión paciente evoluciona favorablemente, se levanta de la cama, solicita agua, es capaz de comer. Síntomas psicóticos ceden tras la tercera sesión, señalando además no recordar nada de lo ocurrido. En entrevista de evolución paciente vigil, orientada TE, actitud parcialmente cooperadora. En cuanto a las psicosis histéricas en sí, es una psicosis aguda, de rápida curación cuando se las trata adecuadamente y Bleuler habla de los llamados estados crepusculares histéricos. La duda diagnóstica es entre un trastorno disociativo tipo psicosis histérica o bien un trastorno psicótico agudo, refiriéndose a trastornos de presunto origen disociativo con sintomatología que podríamos denominar pseudopsicótica. La CIE-10 clasifica las psicosis agudas no afectivas, como Trastornos psicóticos agudos y transitorios (TPAT), (Acute and Transient Psychotic Disorders (ATPD) en inglés), comparten las características comunes de inicio agudo dentro de dos semanas, y la presencia de síntomas psicóticos típicos. La descripción de TPAT fue influenciada por los conceptos de psicosis cicloide, bouffée délirante y psicosis reactiva. No es sorprendente, por lo tanto, que los ATPD de la CIE-10 (al menos diagnósticamente) sean un heterogéneo grupo de trastornos. Tanto los sistemas CIE como DSM se basan en síntomas, y descuentan los aspectos "no empíricos" del diagnóstico, que pueden constituir el «fenómeno" esencia de un trastorno psicótico. Actualmente, no existe una categoría de diagnóstico para definir individuos que están experimentando tal psicopatología y tienen un riesgo significativamente mayor de desarrollar esquizofrenia u otro desorden psicótico. Trastorno histriónico de la personalidad (HPD), como argumento aquí, no es una patología mental real; más bien, "histriónico" se refiere a un rasgo o grupo de rasgos de personalidad que podría conducir a algún otro trastorno mental.

Clinical case. Patient María R.A., 28 years old, Basic schooling in differential program, housewife, Married, 9 years of marriage. His partner is 62 years old. Currently lives with husband and 2 year old son in Maipú. During 2016, Maria consulted in different emergency services, receiving different diagnoses: Conversion and conversion syndrome. Urgency is entered with diagnosis: Syndrome Psychotic lucid. Patient in bed, without spontaneous movements, with rigidity, stare, dehydrated, does not accept to feed, negativist, does not establish visual contact, does not answer simple questions, however, spontaneously can remain talking, giving account of delusional contents. On the day of his admission to the sector, Electro Convulsive therapy was started, and he completed 5 sessions. After the first patient session he progresses favorably, gets up from bed, requests water, is able to eat. Psychotic symptoms give way after the third session, noting also not remember anything of what happened. In an evolution interview, vigil patient , oriented TE, partially cooperative attitude. As for hysterical psychoses per se, it is an acute, rapidly healing psychosis when properly treated and Bleuler speaks of so-called hysterical crepuscular states. The diagnostic doubt is between a dissociative disorder type hysterical psychosis or an acute psychotic disorder. referring to disorders of presumed dissociative origin with symptomatology that we could call pseudopsychotic. The ICD-10 classifies acute non-affective psychoses, as Acute and Transient Psychotic Disorders (ATPD), share the common characteristics of acute onset within two weeks, and the presence of typical psychotic symptoms. The description of ATPD was influenced by the concepts of cycloid psychosis, bouffée délirante and reactive psychosis. It is not surprising, therefore, that the ATPD of the ICD-10 (at least diagnostically) is a heterogeneous group of disorders. Both CIE and DSM systems are based on symptoms and discount the "non-empirical" aspects of diagnosis, which may constitute the "phenomenon" essence of a psychotic disorder. Currently, there is no diagnostic category to define individuals who are experiencing such psychopathology and have a significantly increased risk of developing schizophrenia or other psychotic disorder. Histrionic Personality Disorder (HPD), as an argument here, is not a real mental pathology; rather, "histrionic" refers to a trait or group of personality traits that could lead to some other mental disorder.

Acute Psychosis Following Hydrocortisone Replacement in a Patient with Secondary Adrenal Insufficiency Due to Recurrent Postoperative Pituitary Macroadenoma.

Acute psychosis in patients receiving physiological corticosteroid replacement is rare. The exact mechanism of this disorder is not clear. We report a case of a 50 year old female with recurrent post operative pituitary macroadenoma who had presented to us with features of adrenocortical insufficiency. The patient was started on intravenous (iv) hydrocortisone and after receiving six doses, she developed features of acute psychosis. She was put on anti-psychotics and hydrocortisone was withheld for 24 hrs. The patient recovered in a couple of days and oral hydrocortisone was re-started at 5 mg per/day and increased to 15 mg/day without recurrence of symptoms of psychosis.

Levofloxacin induced psychosis: a rare case report.

Levofloxacin is a commonly prescribed antibiotic for treating bacterial infections in routine clinical practice. A wide range of side-effects have been ascribed to the quinolone group of drugs, the most common being gastrointestinal. Central nervous system is rarely involved; neuropsychiartic complications are among the least reported adverse reactions. We report a rare case of levofloxacin induced acute psychosis in a young male presenting in out-patient department with signs of urinary tract infection along with pneumonitis.

Autobiographical memory deficits in acute transient psychosis after remission

Background : In our clinical practice, in patients who went into clinical remission from their psychotic episodes, we found variability in recall pattern of events and experiences occurring during psychotic states. Aims: The present study aimed to find out the deficits in autobiographical memory regarding the events and experiences which occurred during psychotic states in clinically remitted acute and transient psychotic disorder (ATPD) patients. Method: Consecutive patients (20), who went into clinical remission within a period of three months of onset of their first ATPD episodes, along with their informants (20), who were selected as per specific inclusion and exclusion criteria, were interviewed within a period of two months of clinical remission of their psychotic episodes. The interviews were based on a list which included items regarding different events and experiences restricted to the period of patients' illness and their recall abilities were compared. Results: Catatonic features, features suggestive of dis-inhibition, impairment of personal care, manic features and biological function impairment were the items which patients found difficult to recall. Conclusion: The study showed that the patients had autobiographical memory deficits regarding their catatonic features, dis-inhibitions, personal care and biological function impairments and manic symptoms after their clinical remission, which has clinical and management implications. However the study was limited by the small sample size and naturalistic design. Key message - Patients found it difficult to remember catatonic features, dis-inhibitions, manic symptoms, personal care and biological function impairments which occurred during their psychotic episodes after clinical remission of their acute transient psychotic episodes.

Atypical Thyrotoxic Psychosis with Seizure: A Case Report

Thyrotoxicosis results in alteration in functioning of nervous system in some patients. However, these mental disturbances may be severe in rare cases in the form of manic-depressive, schizoid or paranoid reaction. The pathophysiological basis of these nervous system findings is not well understood.

Cognition Levels of Attendants of Patients with an acute relapse of Psychosis - Differences Immediately Prior to and Post Admission.

Background - Mental illness in a family member has an adverse impact on overall wellbeing of other caregivers. Aims - To study the cognition level of attendants of acutely relapsed psychotic patients. Methods - Two matched groups of 30 attendants each ,of acutely relapsed psychotic patients, who differed on admission status of their patients were administered MMSE and their cognition levels were compared. Results - Cognition level of attendants of acutely relapsed psychotic patients was found to be lower than that of the general population. 40% of attendants awaiting admission and 7% of attendants who had their wards admitted had at least mild cognitive deficit. Further, a likelihood of lower cognition level in attendants awaiting admission as compared to attendants who had had their wards admitted was found to be statistically significant. Conclusion - Attendants of acutely relapsed psychotic patients have a lower cognition level prior to admission and this fact may have implications on deciding the ideal time to obtain history from the attendants and to give them advice and instructions on patient care.

The clinical characteristics of multi acute psychosis disorder without the symptom of schizophrenia

A clinical characteristics prospective study on 55 patients who suffer from acute psychosis disorder and temporary and 30 among them are multi acute rebellious disorder without the symptom of schizophrenia. The result showed that: the average initial age of acute psychosis disorder and temporary: 29.0 ± 11.29. There is no difference between male and female. The rate of acute rebellious disorder and temporary combine with SCTL is low:14.5%. For the multi acute psychosis disorder patient without the symptom of schizophrenia. The onset of disease is often sudden and rapid. Average duration of disease is short and is shorter significantly than that of other acute psychosis disorders as schizophrenia. All of them have delusion, especially persecution illusion (90%), most of them have more than two illusions: (86.7%); the illusion are often occur uncontinuously and temporary, illusion combine with hallucination seen in 70%. Some types of hallucination: fast hallucination: 70%, the content of its hallucination is complicate, mainly hallucination of hearing which appear uncontinuously: 66,7%, hallucination of hearing from outside are often seen: 66.7%. Emotion disorder often seen: anxiety: 50%, mania and depression:46.7%, unstable emotion: 36.7%

Neuroleptic malignant syndrome in a diabetic patient with eye complication and acute psychosis.

Neuroleptic malignant syndrome is a life-threatenting complica-tion of antipsychotic treatment. The prevalence is estimated to be 0.02 to 2.4 percent of patients exposed to dopamine receptor antagonists. Mortality rates are reported to be 10-20 percent. The important clinical signs and symptoms are severe muscle rigidity and fever. Other features are changes in level of consciousness ranging from confusion to coma, autonomic instability and laboratory evidence of muscle injury (eg, elevated CPK). We report a diabetic patient with eye complications and acute psychosis, developing neuroleptic malignant syndrome four days after receiving haloperidol 15 mg/day. The patient recovered well within 5 days after discontinuation of haloperidol and symptomatic treatment and had undergone an eye operation which yielded good result.