Acute Psychosis Due to Anti-N-Methyl D-Aspartate Receptor Encephalitis Following COVID-19 Vaccination
Acute psychosis due to anti-N-methyl D-aspartate receptor encephalitis following #CovidVaccination (Pfizer-BioNTech): https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8599934/
A woman in her 20's. She presented initially with anxiety & hypochondriacal delusions which progressed to psychosis & catatoniaAcute Psychosis Due to Anti-N-Methyl D-Aspartate Receptor Encephalitis Following COVID-19 Vaccination: A Case Report
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.
Introduction
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). This disease was first described in 2007 as a paraneoplastic syndrome in women presenting with ovarian teratomas but has since been designated as the second most common immune mediated encephalopathy (2, 3). Anti-NMDAR encephalitis has been associated with viral illnesses such as Japanese encephalitis, HSV-1, Epstein-Barr virus, and most recently COVID-19 infection (Table 1) (5, 9–11). Additionally, anti-NMDAR encephalitis has been associated with vaccinations against H1N1, yellow fever, TdaP-IPV booster, and the Japanese Encephalitis (3, 12–14). In this case report, we present the first instance of anti-NMDAR encephalitis after receiving the Pfizer-BioNTech COVID-19 vaccine.
Case Narrative
A female in her 20's presented to the Emergency Department (ED) with a chief complaint of urinary frequency 1 week after receiving her first dose of the Pfizer-BioNTech COVID-19 vaccine (Figure 1). The patient's family stated she had increasingly frequent bouts of anxiety, decreased mentally acuity, insomnia, and a fixation that she suffered from irritable bowels and kidney disease. She displayed waxing and waning hypochondriacal delusions that she had contracted COVID-19 and that “her body was shutting down.” The patient was also noted to have some motor dysfunction and a transient bout of aphasia during this time. There were no complaints of antecedent infection, fever, or headache. Family history and past medical history were non-contributary. The physical examination showed tachycardia and hypertension but otherwise unremarkable. Hematology and metabolic labs and urinalysis were normal.
The patient was discharged from the ED with instructions to follow up with her primary care physician but returned the following day with complaints of increasing anxiety as well as continued somatization of bowel and kidney disease. The patient also endorsed accusatory auditory hallucinations but denied suicidal or homicidal ideation. Repeat blood tests demonstrated mild leukocytosis and slightly increased alanine aminotransferase (ALT) and aspartate aminotransferase (AST). The physical exam was again normal except for elevated blood pressure and tachycardia. SARS-CoV-2 nasopharyngeal polymerase chain reaction (PCR) was negative. Due to the persistent tachycardia and hypertension, she was kept overnight for observation. No cerebrospinal fluid (CSF) analysis was performed during these initial two ED visits.
The following morning the patient removed her clothing and had a bowel movement on the floor. With no discovery of metabolic or toxic causes based on bloodwork and imaging for her acute psychosis, she was transferred to an inpatient psychiatric unit for voluntary admission. 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. Risperidone therapy was then trialed (0.5 mg, Q4H), however the patient experienced a grand mal seizure which prompted transfer back to the ED and subsequent admission to the intensive care unit. Detailed question of family members revealed no evidence of upper respiratory, gastrointestinal, or other antecedent illness in the preceding few weeks.
READ THE FULL TEXT HERE: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8599934/
In summary, we present the first case of anti-NMDAR encephalitis complicating SARS-CoV2 vaccination in a previously healthy young woman. This case provides an important reminder that (i) psychiatric clinical presentations warrant a thorough medical workup, including brain imaging, CSF analysis, anti-NMDAR antibody testing, and a vaccine history; (ii) combined therapies of blocking (IVIG), reducing production of (rituximab), and even removing (plasmapheresis) harmful anti-NMDAR may be the optimal strategy to reverse the neurological and psychiatric symptoms driven by anti-NMDAR antibody production. Fortunately, prompt therapy targeting anti-NMDAR antibodies resulted in achieving and sustaining an excellent clinical outcome. In addition to providing clinicians the opportunity to identify potential vaccine-associated anti-NMDAR encephalitis, particular attention may be needed to patients receiving COVID-19 vaccine who have previously have had anti-NMDAR encephalitis.
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