Abstract
Anti-N-methyl D-aspartate (NMDA) receptor (anti-NMDAR) encephalitis has been reported after SARS-CoV-2 infection, but not after SARS-CoV-2 vaccination. We report the first known case of anti-NMDAR encephalitis after SARS-CoV-2 immunization in a young female presenting with acute psychosis, highlighting a rare potential immunological complication of vaccination against SARS-CoV-2 that is currently being distributed worldwide. The patient presented initially with anxiety and hypochondriacal delusions which progressed to psychosis and catatonia but returned to baseline with aggressive immunomodulatory therapy consisting of intravenous immunoglobulin, high-dose glucocorticoids, and rituximab. This study highlights that the workup of acute psychosis should include establishing a history of recent vaccination followed by a thorough neurological assessment, including for anti-NMDAR antibodies in blood and cerebrospinal fluid.
Highlights
Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune mediated condition characterized by complex neuropsychiatric syndromes and the presence of antibodies against the GluN1 receptors in the cerebrospinal fluid (CSF) [1]
While numerous psychiatric conditions, including anti-NMDAR encephalitis, have been shown to complicate COVID-19 infections (Table 1), this case report is the first reported incident of anti-NMDAR encephalitis temporally linked to SARS-CoV-2 vaccination [4, 5, 7, 8, 15]
Instead, based on precedent cases of anti-NMDAR encephalitis caused by vaccines against influenza, yellow fever, Japanese encephalitis, and tetanus/diphtheria vaccines, clinicians in this case quickly considered the recent receipt of SARS-CoV-2 vaccine as a possible trigger of anti-NMDAR encephalitis [3, 12,13,14]
Summary
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune mediated condition characterized by complex neuropsychiatric syndromes and the presence of antibodies against the GluN1 receptors in the CSF [1]. Initial presentation: MRI and CSF analysis was normal awake and sleep EEGs were encephalopathic with widespread delta waves. Treatment was begun with olanzapine and haloperidol (5 mg, Q4H) Despite these therapies, patient became increasingly psychotic, which was initially managed with lithium, but this was discontinued due to symptoms of catatonia. The patient continued to present with a flat affect and increasingly poor volitional initiation of movement and speech. Repeat evaluation of CSF revealed resolution of her lymphocytic pleocytosis (4 WBC/mm, normal ≤) Anti-NMDAR CSF titers had decreased to 1:10. 45 days in the hospital and 61 days after receiving the SARS-CoV-2 vaccine, she was discharged from the hospital with minor neurological deficits She remains well 3 months after hospital discharge on anticonvulsant therapy, with no signs of relapse and has returned to work
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