Background Despite the expanding knowledge base, much remains to be understood about effective treatments to treat the many symptoms of anti-NMDA receptor encephalitis (anti-NMDA RE).

Purpose To describe the treatment options for a case of refractory status epilepticus associated with non paraneoplastic anti-NMDA RE.

Materials and Methods Revised drug-treatment history of the patient.

Results A 22-year-old woman with a family history of epilepsy and an arteriovenous malformation (AVM) of the brain, presented a generalised tonic-clonic without clear focal onset and post-critical confusion. She was in non-convulsive status epilepticus.

Treatment was initiated with various intravenous drugs during the 50 days of the status: diazepam, phenytoin, valproic acid, levetiracetam, clonazepam, midazolam, propofol, lacosamide, ketamine, and lidocaine.

It was decided to proceed with induction of barbiturate coma three times, requiring supratherapeutic doses in the second one. Oxcarbazepine was administered via feeding tube.

With these treatments, momentary remission status was achieved although epileptiform activity reappeared when the pharmacological effect expired.

Thirty days after admission, it was decided to repeat computed tomography for development of AVM and investigate again whether the cerebrospinal fluid was positive for anti-NMDA. This being the case, teatment was initiated with methylprednisolone and immunoglobulins.

She continued with clinical status, but electrical brain activity began to fade at the same time that the patient was starting to tolerate enteral nutrition and so oxcarbazepine possibly began to be absorbed.

After discontinuing sedation the patient awoke and opened her eyes. Electroencephalogram was repeated and epileptiform activity had disappeared completely. Facial dyskinesias were treated with clonazepam.

Conclusions Whereas the best treatment approach for anti-NMDA RE encompasses a combination of immunotherapy, intensive care, and rehabilitation, there is a dearth of information regarding management of psychiatric and behavioural symptoms [1]. The possibility of resolving the status by oxcarbazepine gavage opens a window into the use of drugs by this route in the event of failure of standard treatment.

Reference

1. Sansing LH, Tüzün E, Ko MW, Baccon J, Lynch DR, Dalmau J. A patient with encephalitis associated with NMDA receptor antibodies. Nat Clin Pract Neurol. 2007 May;3(5):291–6.

No conflict of interest.