Multiple Sclerosis and other Neurological Conditions
Cindy Nguyen, MD
Resident Physician
Schwab Rehabilitation Hospital
Chicago, Illinois, United States
Elizabeth Chang, MD
Resident Physician
Schwab Rehabilitation Hospital
Chicago, Illinois, United States
Alexander Plavnik, MS4
Medical Student
American University of the Caribbean School of Medicine
North Miami, Florida, United States
Steven Kreis, DO
Attending Physician; Director - Spasticity Management; Instructor - Electrodiagnostic Medicine
Schwab Rehabilitation
Chicago, Illinois, United States
Fabiolla Kopp, MD
Attending Physician
Schwab Rehabilitation Hospital
Chicago, Illinois, United States
Catatonia in anti-NMDA receptor encephalitis secondary to ovarian teratomas
Case Description:
A 19-year-old woman with a history of anti-NMDA receptor encephalitis in the setting of right ovarian teratoma status post oophorectomy presented for new onset seizures concerning for refractory disease. Given reports of microscopic teratomas associated with persistently elevated NMDA antibodies, she underwent contralateral oophorectomy with some improvement in mental status. The patient subsequently developed catatonia presenting as mutism, echopraxia, perseveration, posturing, and dermatillomania. The patient underwent an interdisciplinary rehabilitation program, augmented by pharmacologic management of catatonia, including treatment with lorazepam and N-acetylcysteine for perseverative behaviors and excoriation disorder. At time of discharge, she demonstrated independence with ambulation without assistive device, and made significant improvements in her auditory comprehension and verbal expression from severe to moderate level of deficit.
Discussions:
Anti-NMDA receptor encephalitis is a life-threatening condition that can significantly impair functional mobility. Catatonia, a common neuropsychiatric sequelae, presents unique challenges to functional recovery. Pharmacologic treatment of catatonic symptoms plays a pivotal role in facilitating engagement in therapeutic interventions. Lorazepam, well-described in treatment of catatonia with its action on GABA-A receptors, can contribute to improvements in vocalization and responsiveness, thereby enhancing the effectiveness of speech-language interventions focused on language elicitation and attention. Additionally, N-acetylcysteine, which modulates glutamatergic activity, may help manage behavioral symptoms such as perseveration, compulsive skin picking, and difficulty with task termination. These improvements are essential to supporting participation in comprehensive therapies to maximize independence in mobility, expression, and self care.
Conclusions:
Recovery from an acquired brain injury due to anti-NMDA receptor encephalitis is prolonged, often with persistent neurocognitive manifestations, such as catatonia, for years after initial injury. This case underscores the importance of a combined approach with pharmacologic management of catatonia and early intensive multidisciplinary rehabilitation to maximize functional outcomes and promote meaningful independence in mobility and cognition.
