Catatonia: A Duel of Hashimoto’s Encephalopathy and Anti NMDA Receptor Encephalitis (P5.166)

Abstract

OBJECTIVE:To present a unique case of diagnostic conundrum in a catatonic patient positive for both anti NMDA receptor and anti TPO antibodies with a normal 24 hour EEG, brain MRI and CSF. BACKGROUND:Catatonia, although typically associated with schizophrenia and other affective disorders, can be an uncommon presenting feature of two rare neurologic disorders: Hashimoto’s encephalopathy and anti NMDA receptor encephalitis. Here we describe a case of anti NMDA receptor encephalitis in a catatonic patient positive for both anti TPO and anti NMDA receptor antibodies with a negative 24 hour EEG, normal brain MRI and CSF. DESIGN/METHODS:Case Report RESULTS:Patient is 33 years old female who presented after 4 weeks of catatonic state punctuated daily by multiple psychotic features such as acute agitation, delusional behavior, visual hallucinations, paranoid ideations. Patient’s 24 hour video EEG revealed no abnormalities. Her initial CSF at 4 weeks was normal and infectious workup for HSV, Lymes’, HIV, WNV, CMV, Cocksackie virus was negative. Autoimmune workup for anti ANA, DS DNA, Smith, RNP, SSA, SSB, SCL was negative. ESR and CRP were normal. Reversible causes of encephalopathy were excluded. Tox screen was negative. Anti-TPO was positive at 135 (norm <35). Repeat LP revealed lymphocytic pleocytosis. NMDA receptor antibody titers were positive. Subsequently, ovarian teratoma was found and excised. Patient responded well to high dose steroids and plasma exchange with gradual but complete recovery. CONCLUSIONS:This case uniquely illustrates that although the diagnosis of NMDA encephalitis is unlikely in the presence of normal EEG, MRI and CSF, it cannot be entirely ruled out. In addition, it serves as a clinical reminder that although anti-TPO antibodies may be positive, they are not always directly correlated with an encephalopathic process and thus the diagnostic workup should not be stopped. Study Supported by:University of Chicago Medical Center

Disclosure: Dr. Grebenciucova has nothing to disclose.