Management of psychiatric symptoms in pediatric anti-NMDA receptor encephalitis: Case report and systematic review

Abstract

Introduction Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune condition that causes serious psychiatric symptoms. Nearly 40% of affected patients are pediatric in age. Few publications detail management of psychiatric symptoms. Objective To guide clinical decision-making for psychiatrists managing pediatric patients with anti-NMDA receptor encephalitis. Aims We present a systematic review of literature and an illustrative case report of a 17-year-old girl who presented with psychosis, agitation, and insomnia, and underwent treatment with olanzapine, clonazepam, and clonidine. Methods PUBMED was searched for publications in English describing anti-NMDA encephalitis (2007–November 2015). Publications were included if they met all of the following: – novel data; – reported treatment of psychiatric phenomena for patients aged ≤18 years – full text available. Thirty-four publications detailing 38 unique cases were included. Results Psychiatric symptoms are summarized in Table 1; common treatment modalities are presented in Table 2. The most frequently used antipsychotics were risperidone ( n =16, 57%), haloperidol ( n =10, 36%), and olanzapine ( n =10, 36%). Significant adverse effects occurred, with neuroleptic malignant syndrome diagnosed with high probability in 4 cases (13%), and suspected in 5 cases (16%). Dystonia, rigidity, tremors, and bradykinesia were also linked to medication side effects. All reported adverse events coincided with antipsychotic administration. Conclusions Psychiatric symptoms in pediatric cases of anti-NMDA receptor encephalitis were frequently managed with antipsychotics and benzodiazepines. Though antipsychotics may be necessary, serious side effects are concerning. Unlike in delirium resulting from other causes, benzodiazepines do not seem to be contraindicated. ECT may also be of utility and was well-tolerated in reported cases.