Missed Opportunities to Prevent N-methyl-D-Aspartate Receptor (NMDAR) Encephalitis in a DREAMer

Abstract

Objective Describe a case of NMDAR encephalitis in a young Latino male patient, additionally the factors resulting in delayed preventative and diagnostic medical care, which contributed to the development of a preventable case of NMDAR encephalitis. Background Adolescent undocumented immigrants in the United States face a history of prejudice and bias that perpetuates disparities and stigmas related to their healthcare. The lack of culturally informed practices among healthcare workers can create multiple lost opportunities to deliver standard of care practices, including routine testicular exams. The treatment of NMDAR encephalitis with immunotherapy, and resection of culpable tumors when present, can be lifesaving. Recognition of the germ cell tumor association has also renewed awareness of the importance of screening for such tumors. Design/Methods N/A. Results Case: A 25-year-old male who immigrated from Mexico to the U.S. at age 13 presented to the hospital for concern of status epilepticus. His past medical history included atypical developmental delay beginning in late teenage years. A large abdominal mass was identified on imaging as a stage IIIC (pT1bN0M1bS2) NSGCT (70% teratoma/30% seminoma) tumor arising from an unresected, undescended left testicle. Autonomic instability in the setting of this malignancy prompted an evaluation for, and diagnosis of, NMDAR encephalitis. His course was complicated by altered mental status, seizures, sympathetic storming, and orofacial dystonia. After tumor resection, and initiation of immune therapy, the patient showed a remarkable recovery. Conclusions This patient's preventive healthcare was impacted at multiple timepoints by changing political policies and a lack of culturally informed practices that unpredictably disrupted reliable access to medical care. Recognition of care gaps allows us to expand our differential diagnoses, and enact a comprehensive approach to fill in gaps. Effective communication, incorporating focused discussions within culturally sensitive frameworks, requires ongoing education for clinicians regarding the populations they serve to prevent disease and minimize health care disparities.