Haider Maryam B, Din Noren, Dar Sophia, Basida Brinda
Internal Medicine, Detroit Medical Center/Wayne State University, Sinai-Grace Hospital, Detroit, USA.
Internal Medicine, Hackensack University Medical Center, Hackensack, USA.
Cureus. 2022 Jul 1;14(7):e26496. doi: 10.7759/cureus.26496. eCollection 2022 Jul.
Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is an autoimmune disorder affecting the N-methyl-D-aspartate receptors in the central and peripheral nervous systems. Gastrointestinal (GI) complications are rarely manifested in this disease. Autoimmune dysregulation of the GI tract is considered a potential cause. We present a challenging case of a 38-year-old male with a history of newly diagnosed epilepsy. He was admitted for three weeks of confusion, hallucinations, and bizarre behavior, and was later diagnosed with anti-NMDA encephalitis from a cerebrospinal fluid (CSF) immunological study. He was treated with a five days course of intravenous immunoglobulin (IVIG) and high-dose steroids. His course was further complicated with GI obstruction and upper GI bleed. His laboratory workup showed lactic acidosis and there was a concern for ischemic bowel injury. Computed tomography (CT) of the abdomen with contrast showed diffuse moderate to pronounced dilated small intestine swirling the mesenteric vessels, concerning for intestinal vascular compromise. The patient also became tachypneic and hypoxic, requiring 6 L of oxygen with a venti-mask. CT of the chest, abdomen, and pelvis with contrast revealed saddle pulmonary embolism (PE) extending to the right and left pulmonary arteries with right heart strain. He underwent emergent explorative laparotomy and emergent catheter-directed thrombectomy. Neither necrotic bowel nor any evidence of perforation or volvulus was noted during the laparotomy; however, the small bowel and the colon were reported to be significantly dilated, hyperemic, and engorged with blood without any evidence of ischemic bowel. He had a complicated 29-day admission course and recovered functional capacity to be safely discharged to a skilled nursing facility for further care. Physicians should keep in mind the gut-brain axis and autonomic effects on gut receptors of any patient presenting with psychosis and seizure disorder to provide timely care and improve morbidity and mortality in this patient population.
抗 N-甲基-D-天冬氨酸（抗 NMDA）受体脑炎是一种自身免疫性疾病，会影响中枢和外周神经系统中的 N-甲基-D-天冬氨酸受体。胃肠道（GI）并发症在该疾病中很少表现出来。胃肠道的自身免疫失调被认为是一个潜在原因。我们报告了一例具有挑战性的病例，一名 38 岁男性，有新诊断癫痫病史。他因三周的意识模糊、幻觉和怪异行为入院，后来通过脑脊液（CSF）免疫学研究被诊断为抗 NMDA 脑炎。他接受了为期五天的静脉注射免疫球蛋白（IVIG）和高剂量类固醇治疗。他的病情因胃肠道梗阻和上消化道出血而进一步复杂化。他的实验室检查显示乳酸酸中毒，人们担心存在缺血性肠损伤。腹部增强计算机断层扫描（CT）显示小肠弥漫性中度至明显扩张，肠系膜血管呈漩涡状，提示存在肠血管受损。患者还出现呼吸急促和低氧血症，需要使用面罩吸氧 6 升。胸部、腹部和骨盆增强 CT 显示鞍状肺栓塞（PE）延伸至左右肺动脉，伴有右心劳损。他接受了紧急剖腹探查术和紧急导管定向血栓切除术。剖腹手术中未发现坏死肠段，也没有穿孔或肠扭转的迹象；然而，据报告小肠和结肠明显扩张、充血且充满血液，没有缺血性肠的证据。他有一个复杂的 29 天住院病程，恢复了功能能力，得以安全出院至专业护理机构接受进一步护理。对于任何出现精神病和癫痫障碍的患者，医生应牢记肠脑轴以及自主神经对肠道受体的影响，以便及时提供护理并改善该患者群体的发病率和死亡率。
