1266

Abstract

Case Reports: The mediastinum is a rare site for occurrence of teratomas, as most documented cases are ovarian in origin. In this particular instance, the patient did not present with the most common signs of shortness of breath or retrosternal pain or fullness, but instead with an acute psychotic episode and refractory non-convulsive status epilepticus. Unique presentations such as this one often force healthcare providers to think “outside the box” when determining the cause of non-convulsive status. In late 2009, a previously healthy 19 year old female college student began having emotional labiality which quickly progressed to uncharacteristic hostility, religious preoccupation, and visual hallucinations. When she became aggressive towards her college professor and classmates, she was arrested and taken to a local emergency department. Upon examination she denied any complaint and had no recollection of her previous bizarre behavior. Shortly thereafter, she began seizing despite the fact that her head CT, MRI, and LP all lacked acute abnormalities. She was intubated and transferred to the neuro intensive care unit at our tertiary care center. Upon arrival patient was noted to have nystagmus, and rhythmic facial movements, as well as an EEG confirming non-convulsive status. The status epilepticus was refractory to a variety of treatments including; benzodiazepines, multiple anti-epileptic drugs (phenytoin, levetiracetam, oxcarbazepine, valproate, and phenobarbital), repeated drug induced coma, resection of a mature mediastinal teratoma, intravenous steroids, rituximab, and plasmapheresis. Her seizures were eventually controlled using felbamate, an anti-epileptic with known anti-NMDA receptor antagonist properties. Once the neoplasm was removed, the episodes of psychosis resolved suggesting they were likely secondary to the anti-NMDA antibodies. Besides status, her critical care course was complicated by limbic encephalitis, acute respiratory failure requiring tracheostomy, and bilateral pneumothoraces. After a prolonged hospital course, she was eventually discharged with minimal functional deficits, and able to return back to college full-time. This case represents a unique presentation of mediastinal teratoma and non-convulsive status epilepticus. When considering the complex differential diagnosis of acute psychosis, critical care providers may need to consider psychiatric symptoms as potential early manifestations of non-cranial paraneoplastic syndrome.