VA Boston Healthcare System, Boston, MA, USA.
Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
Psychol Med. 2019 Dec;49(16):2709-2716. doi: 10.1017/S0033291718003665. Epub 2018 Dec 18.
Anti-NMDA receptor (NMDAr) encephalitis is the most common autoimmune encephalitis in adults. It mimics psychiatric disorders so often that most patients are initially referred to a psychiatrist, and many are misdiagnosed. Without prompt and effective treatment, patients are likely to suffer a protracted course with significant residual disability, or death. This study focuses on the frequency and chronology of salient clinical features in adults with anti-NMDAr encephalitis who are likely to be first evaluated by a psychiatrist because their presentation suggests a primary psychiatric disorder.
A systematic search of PubMed and EMBASE databases identified published reports of anti-NMDAr encephalitis associated with prominent behavioral or psychiatric symptoms. After eliminating redundancies, the frequencies and relative timing of clinical features were tabulated. Signs and symptoms were assigned temporal ranks based on the timing of their first appearance relative to the first appearance of other signs and symptoms in each patient; median ranks were used to compare temporal sequencing of both individual features and major symptom domains.
Two hundred thirty unique cases (185 female) met study inclusion criteria. The most common features were seizures (60.4%), disorientation/confusion (42.6%), orofacial dyskinesias (39.1%), and mutism/staring (37.4%). Seizures, fever, and cognitive dysfunction were often the earliest features to emerge, but psychiatric features predominated and sequencing varied greatly between individuals.
Clinicians should consider anti-NMDAr encephalitis when new psychiatric symptoms are accompanied by a recent viral prodrome, seizures or unexplained fever, or when the quality of the psychiatric symptoms is unusual (e.g. non-verbal auditory hallucinations).
抗 N- 甲基-D- 天冬氨酸受体（NMDAr）脑炎是成人中最常见的自身免疫性脑炎。它常常模仿精神疾病，因此大多数患者最初被转诊给精神科医生，许多患者被误诊。如果没有及时有效的治疗，患者可能会经历一个漫长的病程，出现严重的残留残疾，甚至死亡。本研究重点关注那些因表现出主要精神障碍而首先由精神科医生评估的抗 NMDAr 脑炎成人患者中显著临床特征的频率和时间顺序。
系统检索 PubMed 和 EMBASE 数据库，以确定与突出的行为或精神症状相关的抗 NMDAr 脑炎的已发表报告。消除重复项后，列出了临床特征的频率和相对时间顺序。根据每个患者中首次出现其他体征和症状的时间，将体征和症状分配时间等级；中位数等级用于比较个体特征和主要症状域的时间顺序。
符合研究纳入标准的 230 例（185 例为女性）独特病例。最常见的特征是癫痫发作（60.4%）、定向力障碍/意识模糊（42.6%）、口面部运动障碍（39.1%）和缄默/凝视（37.4%）。癫痫发作、发热和认知功能障碍常常是最早出现的特征，但精神特征占主导地位，个体之间的顺序差异很大。
当新出现的精神症状伴有近期病毒前驱症状、癫痫发作或不明原因发热，或者精神症状的性质不寻常（例如非言语性听觉幻觉）时，临床医生应考虑抗 NMDAr 脑炎。
