Anti-N-methyl-D-aspartate receptor antibodies: A potentially treatable cause of encephalitis in the intensive care unit

• Published in: Critical care medicine Vol. 38; no. 2; pp. 679 - 682
• Main Authors: Davies, Gerard, Irani, Sarosh R, Coltart, Cordelia, Ingle, Gordon, Amin, Yogen, Taylor, Christopher, Radcliffe, Jeremy, Hirsch, Nicholas P, Howard, Robin S, Vincent, Angela, Kullmann, Dimitri M
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD by the Society of Critical Care Medicine and Lippincott Williams & Wilkins 01-02-2010; Lippincott Williams & Wilkins
• Subjects: Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Autoantibodies - immunology; Biological and medical sciences; Clinical death. Palliative care. Organ gift and preservation; Dyskinesias - etiology; Dyskinesias - immunology; Encephalitis - etiology; Encephalitis - immunology; Encephalitis - therapy; Female; Humans; Immunomodulation; Intensive care medicine; Intensive Care Units; Male; Medical sciences; Psychotic Disorders - etiology; Psychotic Disorders - immunology; Receptors, N-Methyl-D-Aspartate - immunology; Seizures - etiology; Seizures - immunology; Stereotypic Movement Disorder - etiology; Stereotypic Movement Disorder - immunology; Encephalitis; Nervous system diseases; Intensive care; Teratoma; neurological intensive care; ovarian teratoma; Glutamate receptor; Intensive care unit; Cerebral disorder; Hyperkinesia; Ovary; Female genital system; Central nervous system disease; NMDA; Tumor; Neurological disorder; NMDA receptor; Psychomotor disorder; hyperkinetic; Resuscitation
• ISSN: 0090-3493; 1530-0293
• DOI: 10.1097/CCM.0b013e3181cb0968

OBJECTIVE:To report the occurrence of an unusual neurologic disorder requiring admission to the intensive care unit.
DESIGN:Analysis of an observational cohort study of 31 patients with encephalitis admitted over a 4-yr period.
SETTING:Neurologic intensive care unit in a tertiary referral center.
PATIENTS:We identified N-methyl-D-aspartate receptor antibodies in six patients (two male and four female). All seropositive patients presented with a psychiatric prodrome, before developing seizures and obtundation requiring intensive care unit admission. They exhibited limb and truncal stereotypies and orofacial dyskinesias upon weaning sedation. Two patients had ovarian tumors.
INTERVENTIONS:Patients were treated with sedation, antiepileptic drugs, and immunotherapy. One patient received a magnesium infusion and ketamine.
MEASUREMENTS AND MAIN RESULTS:N-methyl-D-aspartate receptor antibodies were identified in serum samples by an immunofluorescent cell-based assay. Three patients made a good but slow recovery; two were left with severe neurologic deficits; and one died after return to the referring hospital. These patients accounted for approximately 20% of all patients admitted with encephalitis to this referral center.
CONCLUSIONS:N-methyl-D-aspartate receptor antibodies should be tested in patients with hyperkinetic encephalitis and neuropsychiatric prodrome admitted to the intensive care unit. The disorder is probably not rare and is potentially treatable.