A 25-year-old woman presented with a high respiratory condition.
In the following two weeks, while the respiratory syndrome was dissolved, the family observed conductive changes.
He was generally cheerful and expansive.
One morning he was unconscious in the bathroom.
She was taken to the emergency service and a brain CT scan was performed, which was normal.
An encephalocraneal trauma was diagnosed, indicating rest and analgesics.
At home he remained strange and irritable, became inadequate, and developed intense aggression.
Again evaluated in emergency by a neurologist, he is described as disoriented, perseverative, incoherent, unable to perform simple calculation with an explicit sexual behavior regarding the mental disorder.
The patient was hospitalized, with 340 lymphocytes, proteins of 54 mg/dl and glucose of 55 mg/dl. Cerebrospinal cold treatment was started, with the diagnosis of viral encephalitis.
Consciousness commitment continued to progress to coma and required invasive ventilatory assistance.
Brain MRI showed no abnormalities.
EEG showed slow activity in theta-delta range.
The patient maintained fluctuations in surveillance without regaining consciousness, circumstantially mobilized his four limbs spontaneously.
In syphilis studies herpes simplex virus 1 and 2, cytomegalovirus, Epstein&#146;s virus JC, HTLV-1, HIV, hepatitis B and C virus, and enterovirus were ruled out.
After reviewing the literature, autoimmune encephalitis mediated by antibodies against NMDA receptor was postulated.
Serum and CSF samples were sent to the Neurology Department of the University of Pennsylvania for analysis according to the technique described by Dalmau et al.
CT scans of the chest, abdomen and pelvis revealed no images suggestive of neoplasia.
Methylprednisolone boluses were administered for five days without clinical improvement.
The patient remained conscious, with almost continuous orofacial dyskinesias and respiratory dysrhythmia requiring mechanical ventilation.
After three weeks, due to the steady state of the patient, plasmapheresis was started, removing 1 to 1.5 volumes of plasma per session on alternate days.
After completion of the third plasmapheresis, she began to acquire vigilance and gaze, orofacial movements became less intense and developed generalized stiffness that required the use of levodopa.
The surveillance periods gradually increased and began to comply with simple orders.
There were rhythmic flexion-extension movements of the lower extremities, a motor stereotypy, apparently involuntary.
After the eighth session of plasmapheresis, extubation was achieved.
At this stage, the presence of anti-NMDAr antibodies in CSF and serum was confirmed.
After 45 days, the patient was discharged from the critical care unit.
He remained disoriented, with severe memory impairment, without involuntary movements.
He usually did not recognize his treating physician, nor managed to solve elemental calculus.
A neuropsychological assessment that included attentional ability, visuo-conceptual skills, language, verbal episodic memory and executive functions revealed a multifaceted cognitive impairment.
The minimental was 18/30.
Upon discharge, the patient was monitored one month later.
The patient continued to improve the cognitive-motor aspects, although family members still perceived an unjustified behavior.
She remained abstrated, did not participate in domestic activities, maintained little verbal communication, without formal language alterations.
A transvaginal ultrasound showed a complex cyst of the left ovary.
The control CSF was normal at the cytochemical examination, although the level of anti-NMDA receptor antibodies remained high.
A second neuropsychological control study showed significant improvement in performance.
Five months after the onset of the disease, the patient did not show segmental neurological alterations, had improved intellectual condition and affective behavior, although puerile and capricious attitudes persisted.
