Anti-NMDA Receptor Encephalitis: Highlights in Adult Patients

Anti-NMDA Receptor Encephalitis

By Alex Koyfman MD
Edited by Stephen Alerhand MD

 Your next 3 patients…

1) 21yo F with change in behavior / depressed consciousness
2) 25yo F with “weird movements” brought in by family
3) 30yo F with AMS + increased muscle tone

NMDAR encephalitis patient


– 1st case described in 2005
– Pathogenesis mediated by antibodies against NR1-NR2 heteromers of the NMDA receptor; unclear precipitating factor
– Patients often brought to the ED by family members 2/2 bizarre behaviorNMDA receptor

Clinical considerations

– Median age early 20s
Female predominance
Initial flu-like illness that progresses over 1-2 weeks => psychosis, AMS, dyskinesias, seizures, autonomic instability
– Other symptoms: increased muscle tone, new psychiatric symptoms (agitation, hallucinations, sleep disturbance, paranoia), AMS, memory problem, movement disorder (dyskinesias), autonomic instability, seizure
– think limbic encephalitis (affects hippocampus and limbic system)

Differential diagnosis

– Encephalitis, brain mass, endocrine emergency, NMS, serotonin syndrome, Psych, ketamine / PCP intoxication; when considering these, add anti-NMADR encephalitis to your list

– About 60% found to have cancer (paraneoplastic), most commonly ovarian teratoma


CSF and serum sent for antibodies


Supportive care
High-dose steroids / IVIG / plasma exchange
– Cancer surgery PRN (the earlier the better)


– About 75% cured with no / mild deficit(s)
– 7% mortality

Examples of Treatment Algorithms

(Kruse, Jennifer L. et al. Anti-N-methyl-d-aspartate receptor encephalitis: A targeted review of clinical presentation, diagnosis, and approaches to psychopharmacological management. American Academy of Clinical Psychiatrists, Feb 2014.)

AACP algorithm


(Li, L. Wang, CB. Zaho, G. Anti-N-methyl-D-aspartate- receptor encephalitis in China. Neuroimmunology and Inflammation, June 2014)


Further Reading (see Comments section for enlightening cases) (patient’s view)

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