(065) "The Early Bird Gets the Worm": Case Comparison of Early ECT Intervention in Two ‘Parallel’ Patients with NMDAR Encephalitis with Ovarian Teratoma

Abstract:

Background: Electroconvulsive therapy (ECT) continues to be an essential consideration in the treatment of anti-NMDA receptor (NMDAR) encephalitis. Nonetheless, the proper deployment of ECT in this subset of patients is not well understood (Coffey 2016). We compared two patients with similar presentations of NMDAR encephalitis and their disparate outcomes. We hypothesize that the early introduction of neuromodulation accounts for the differences between these two patients.



Case History: Two young females presented with new-onset neuropsychiatric symptoms and a subsequent diagnosis of NMDAR encephalitis. They received immunosuppressive agents, underwent oophorectomy for ovarian teratomas, and received ECT for malignant catatonia. Patient #1 was a 24-year-old female who received a lorazepam peak of 82 mg/24 hours and underwent ECT on day 21 from symptom onset lasting 49 days. Psychiatric symptoms resolved, she had a near-complete functional recovery, and she did not require maintenance ECT. Patient #2 was a 38-year-old female who received a lorazepam peak of 74 mg/24 hours and underwent ECT on day 61 from symptom onset lasting 56 days. She experienced more medical morbidity and only partial lysis of catatonic symptoms without returning to premorbid functional status.



Discussion: Case reports have demonstrated how the synergistic use of ECT with first-line immunotherapy may help to improve recovery times with shorter hospital stays (Tanguturi 2019). This case comparison builds on the previous literature and supports the early implementation of ECT in promoting functional recovery. We hypothesize that prolonged encephalitis, depleted physical reserve, and poor nutritional intake result in further neurotoxicity responsible for lingering debility. Given the overall safety and tolerability of ECT in these patients (Warren 2019), early implementation of ECT may reduce neurotoxicity, reduce medical morbidity, and promote functional recovery.



Conclusion: ECT continues to be an important treatment option for patients with NMDAR encephalitis, particularly those with catatonia. Earlier recognition and initiation of ECT in these patients may improve cognitive and functional recovery, though more research is necessary. Clinicians should consider the role of ECT early in the treatment of these patients.

References:

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   Tanguturi YC, Cundiff AW, Fuchs C. Anti-N-Methyl d-Aspartate Receptor Encephalitis and Electroconvulsive Therapy: Literature Review and Future Directions. Child Adolesc Psychiatr Clin N Am. 2019 Jan;28(1):79-89. doi: 10.1016/j.chc.2018.07.005. Epub 2018 Aug 24. PMID: 30389078.
   
   


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   Warren N, Grote V, O'Gorman C, Siskind D. Electroconvulsive therapy for anti-N-methyl-d-aspartate (NMDA) receptor encephalitis: A systematic review of cases. Brain Stimul. 2019 Mar-Apr;12(2):329-334. doi: 10.1016/j.brs.2018.11.016. Epub 2018 Dec 4. PMID: 30528383.