A case of anti-NMDA receptor encephalitis amid the COVID-19 pandemic

ABSTRACT

Background: COVID-19 has been linked to neuropsychiatric symptoms, including delirium, depression/anxiety, PTSD, and rarely, severe neuropsychiatric impairment. However, much remains unknown. We present a case of anti-NMDA receptor encephalitis in a patient with concurrent COVID-19 infection. Case History A 27-year-old male who carried diagnoses of unspecified mood versus psychotic disorder was admitted with atypical psychosis and suicidal ideation. Patient initially presented to primary care with racing thoughts, delusions, depression (PHQ-9517), anxiety (GAD-7510), and new onset cognitive symptoms along with olfactory hallucinations. He endorsed daily suicidal ideations and reported using two cellphones to block suicidal waves and enhance his memory. He was admitted to inpatient psychiatry where he exhibited disorganized behavior and paranoid delusions, and reported visual hallucinations. Initial workup of EEG, brain MRI, and TSH were unremarkable. Two months after admission, he developed sore throat and fever and tested positive for COVID-19. Patient developed streaky opacites on chest X-ray, was transferred to the ICU, and intubated due to agitation. Once extubated, he experienced repeated epileptic seizures despite multiple antiepileptics, and lumbar puncture ultimately revealed anti-NMDA receptor antibodies. Symptoms slowly improved with plasmapheresis, steroids, and Rituximab. Conclusions: Case reports suggest that some patients may present with neuropsychiatric symptoms or experience neuropsychiatric sequelae following COVID-19 infection. Infection itself can precipitate an autoimmune encephalitis and may also cause neurological damage which can unmask other neuropsychiatric conditions. This case highlights that research is needed to understand the intersection between COVID-19 infection and mechanisms implicated in other neuropsychiatric disorders, including the spectrum of autoimmune encephalitides.