Case Report And Literature Review Of Autoimmune Encephalitis With Onset Of Psychiatric Symptoms

Objective:To analyze the clinical manifestations,antipsychotic treatment and prognosis of autoimmune encephalitis with onset of psychiatric symptoms,in order to improve psychiatrist's recognition of them to facilitate timely referral and avoid treatment delay.We reviewed the literatures on the evaluation and treatment of catatonia and agitation symptoms of autoimmune encephalitis to improve the cooperation between psychiatry and neurology for the treatment of this disease.Method:Two cases from Peking University Sixth Hospital and three cases from Peking Union Medical College Hospital were analyzed,including the psychiatric symptoms,somatic symptoms,nervous system signs,and antipsychotic treatment efficacy and prognosis.At the same time,literature on the EMBASE,PubMed,China National Knowledge Infrastructure and Wanfang Database from May 2000 to May 2018 were systematically searched and reviewed,with keywords including autoimmune encephalitis,anti-NMDAR encephalitis,agitation,catatonia,and treatment.Results:1.Psychiatric symptoms:five patients experienced hallucinations,delusions,abnormal behaviors,depression,sleep disturbances,and self-injury.Four of these patients first visited a psychiatric hospital.Among them,two patients were misdiagnosed as conversion disorder or depression,another two were diagnosed as "Excitatory state,organic mental disorders?acute and transient psychotic disorders?";2.Somatic symptoms:2 of 5 patients had a history of fever before psychiatric symptoms,4 had epileptic seizures,3 had autonomic dysfunction,2 had abnormal perioral movements,and 1 had disturbance of consciousness;3.Neurological examination:two patients had positive bilateral pyramidal signs,one had showed hypermyotonia,and one showed ataxia;4.Five patients were treated with cortisoland IVIG after being diagnosed as autoimmune encephalitis.Five of them were treated with methylprednisolone and IVIG,followed by oral administration of prednisone.Two of these patients were treated with combination of mycophenolate mofetil tablets;5.All 5 patients were treated with antipsychotic drugs.Among them,three were given olanzapine,1 was given perphenazine,and 1 was given olanzapine combined with haloperidol.3 patients were treated with sodium valproate,a mood-regulatory stabilizer.3 patients were given benzodiazepines,including diazepam,oxazepam and clonazepam;6.After the treatment of antipsychotics,mood stabilizer,and sedative drugs,the psychiatric symptoms of 5 patients were effectively controlled,so that they can cooperate with further examination and treatment.7.Five patients were treated with cortisol and IVIG and the condition improved significantly;8.Treatment plans for agitation and catatonia in autoimmune encephalitis include pre-treatment assessment,drug therapy,non-drug treatment,and nursing.Conclusion:1.For patients with acute or subacute onset of psychiatric symptoms at the psychiatry department,psychiatrists need to consider the possibility of autoimmune encephalitis.It is necessary to improve the relevant medical history and neurological examination to observe whether there is dyskinesia,language disturbance,disturbance of consciousness,or dysmnesia.If so,referred patients timely to reduce misdiagnosis;2.For autoimmune encephalitis with onset of psychiatric symptoms,antipsychotic treatment,mood stabilizer,and sedative treatmentI was conducive to control psychiatric symptoms,improve the compliance of patients,and ameliorate the prognosis;3.At present,the treatment of agitation symptoms of autoimmune encephalitis has been relatively complete.Pre-assessment of the symptoms of agitation of autoimmune encephalitis is necessary.After the assessment,depending on the severity of the symptoms,choose the appropriate treatment plan.Environmental and behavioral attitude management can be the preferred treatment of for non-aggressive and violent patients;drug therapy can be applied to patients who have hostile,uncooperative,impulsive behavior or have a PANSS-EC score greater than 20 or environmental and behavioral management is ineffective;Physical management or electroconvulsive therapy is the last choice;4.For the treatment of catatonia symptoms of autoimmune encephalitis,drug therapy is the preferred treatment.If the drug treatment is not effective,electroconvulsive therapy is the last choice.At the same time,we should pay attention to whether such patients had comorbid physical complications and strengthened nursing.