Anti NMDA RECEPTOR ENCEPHALITIS
Description
● Definition:
an autoimmune encephalitis brought on by antibodies that target the NMDA glutamate receptor, typically against the NR1 subunit. presents with a neurological progression (seizures, movement disorders, decreased consciousness, autonomic instability) after an early psychiatric phase (acute psychosis, agitation, bizarre behaviour).
● Epidemiology:
The most prevalent autoimmune encephalitis in young adults, it most frequently affects young women and can be paraneoplastic (ovarian teratoma), though it can also affect men and children. Immunotherapy and tumour removal can help many people recover, but recovery can take months.
●Typical clinical course & red flags (what brings patients to psychiatry)
●Prodrome: symptoms similar to a virus that last for about a week or two.
➣The psychiatric stage includes symptoms that are frequently confused with primary psychosis, such as acute onset agitation, frank psychosis, paranoia, hallucinations, insomnia, and bizarre behaviour.
➣Neurological stage (often follows days–weeks):
seizures, orofacial and limb dyskinesias, autonomic instability (hypoventilation, BP/HR fluctuations), respiratory compromise, orofacial and limb dyskinesias, catatonia, and language dysfunction (echolalia, mutism). A subset of EEGs may exhibit extreme delta brush, which is linked to prolonged course and intensive care unit needs.
➣Red fdelays in mental health settings (cause an urgent neurology evaluation): Acuteabnormal movements or seizures associated with acute psychosis.
Days of rapid progression, diminished consciousness, or new autonomic symptoms.
Abnormal EEG, or rapid decline following standard antipsychotic treatment failure.) Diagnostic workup (what the team should do)
Immediate tests:
routine lab tests, including electrolyte and infection screening, brain MRI (which may be normal or show medial temporal/limbic changes), serum + CSF anti-NMDAR antibody testing (CSF more sensitive), and EEG. Pelvic ultrasound/CT/MRI in women to look for ovarian teratoma.
Useful findings:
EEG is frequently abnormal (prognostic signal: slow activity or extreme delta brush pattern). There may be oligoclonal bands or CSF pleocytosis. Antibody positivity confirms diagnosis.
● Medical management overview & major challenges clinicians face
➣ Main treatments:
1. First-line immunotherapy: high-dose IV methylprednisolone ± IVIG or plasma exchange.
2. Second-line if inadequate response: rituximab or cyclophosphamide.
3. Tumour removal (if teratoma) improves outcome and is essential when present.
4. Supportive ICU care for autonomic instability and hypoventilation (mechanical ventilation when needed). Seizure control with AEDKey clinical problem (often insufficient until immunotherapy takes effect).
Delayed diagnosis:
Important time is lost because early mental symptoms can be mistaken for primary mental disorders.
Severe autonomic and respiratory failure:
requires ICU-level care and coordination across teams.
Complex medication balancing: sedatives/antipsychotics vs. risk of worsening dyskinesia/respiratory drive; immunosuppression increases infection risk.
Long recovery & rehab needs: cognitive, psychiatric, motor deficits persist — long inpatient or rehab phases are common.
Protocol
● Typical clinical course & red flags (what brings patients to psychiatry)
➣Prodrome: viral-like symptoms for about a week or two.
➣Psychiatric stage: Symptoms that are frequently confused with primary psychosis include sudden onset agitation, frank psychosis, paranoia, hallucinations, sleeplessness, and strange behaviour.
•Neurological stage (often follows days–weeks): seizures, orofacial and limb dyskinesias, autonomic instability (hypoventilation, BP/HR fluctuations), respiratory compromise, orofacial and limb dyskinesias, catatonia, and linguistic impairment (echolalia, mutism). A subgroup of EEGs may exhibit severe delta brush, which is linked to longer course and intensive care unit needs.
➣Red flags in psychiatric settings (trigger urgent neurology workup):
• Aberrant movements or seizures associated with acute psychosis.
• New autonomic symptoms, diminished awareness, or rapid progression over days.
• Rapid worsening following typical antipsychotic treatment failure or abnormal EEG.
●Diagnostic workup (what the team should do)
➣Immediate diagnostics include basic lab work, including electrolyte and virus screening, brain MRI (which may be normal or indicate medial temporal/limbic abnormalities), EEG, and serum + CSF anti-NMDAR antibody testing (which is more sensitive in CSF). Women can use pelvic ultrasound, CT, or MRI to check for ovarian teratomas.
➣Useful findings: EEG is frequently abnormal (prognostic signal: sluggish activity or severe delta brush pattern). There may be oligoclonal bands or CSF pleocytosis. A positive antibody confirms the diagnosis.
●Medical management overview & major challenges clinicians face
➣Main treatments:
1. First-line immunotherapy: plasma exchange or high-dose IV methylprednisolone ± IVIG.
2. Second-line treatment if response is insufficient: cyclophosphamide or rituximab.
3. If a teratoma is present, tumour excision is necessary and improves the result.
4. Supportive intensive care unit treatment for hypoventilation and autonomic instability (mechanical ventilation when required). AED-assisted seizure control is frequently inadequate until immunotherapy is used.
➣Key clinical problems teams face:
•Delayed diagnosis: Important time is lost since early mental symptoms might be mistaken for fundamental mental problems.
•Severe autonomic and respiratory failure: necessitates team collaboration and ICU-level care.
•Complex medication balancing: antipsychotics and sedatives against the chance of respiratory drive and dyskinesia getting worse; immunosuppression raises the danger of infection.
•Long recovery & rehab needs: Long periods of inpatient treatment or rehabilitation are typical, and cognitive, mental, and motor impairments continue.
●Nursing management
Below is an operational nursing guide that includes thorough interventions, explanations, monitoring recommendations, and documentation points. It is intended for immediate use by ward nurses before being transferred to ICU or neuro-rehab teams.
➣Initial triage / admission (psychiatric or medical ward)
•Checklist for riage upon admission:
• Does it have an acute or subacute onset and develop quickly? Y/N •Are you experiencing seizures, atypical movements, or diminished responsiveness? Y/N
•Is there hypoventilation, oxygen desaturation, or autonomic instability (labile BP/HR)? Y/N
•As soon as possible, put the patient on continuous cardiac and SpO₂ monitoring.
•If you haven't already, get an urgent neurology consultation, an EEG, and CSF tests.
● Observation & monitoring (what nurses must do every shift)
•The following neurological observations are charted hourly when unstable and 4-hourly when stable: •GCS/AVPU, pupil response, verbal capacity, and the presence or frequency of aberrant movements or dyskenesias.
•Monitoring seizures: pre/post ictal condition, duration, triggers, and record semiology. If video-EEG is available, request it for episodes that appear to be short dystonic occurrences or FBDS.
•Continuous HR/BP, temperature, and recording of bouts of fever, arrhythmia, hypertension, and hypotension are all examples of autonomic monitoring. Follow routine and notify the medical staff of any inexplicable swings.
•Respiratory monitoring: continuous SpO₂; watch for shallow breathing, hypoventilation, and the requirement for airway suctioning; if there are repeated desats or reduced effort, transfer to the intensive care unit as soon as possible.
(Rationale: autonomic and respiratory failure are common causes of rapid deterioration.)
➣Behavioral & safety management (psychiatric symptoms)
•Low-stimulus environment: minimise visitors at first, have a single room if at all feasible, and have soft lighting.
•Level of observation: 1:1 (continuous) for patients with significant agitation or suicidal thoughts; continuous visual monitoring for individuals at high risk.
•De-escalation first: restrict constraints, use a gentle approach, and de-escalate verbally. Under medical supervision, administer pharmacological sedative (benzodiazepines are recommended for severe agitation or catatonia).
•Antipsychotics can be administered, but watch for neuroleptic malignant-like responses and dyskinesias.
•Seclusion/restraint: only in cases of imminent risk and in accordance with local regulations; make sure that paperwork and review are done often.
(rationale: protecting patients without concealing neurologic decline.)
➣Seizure care (practical)
•Right away: secure IV access, maintain oxygen and suction at the bedside, and pad bed rails. Teach employees how to accurately report events and place patients in a safe manner.
•Medication: start maintenance AEDs as directed; provide benzodiazepines for status/seizure clusters in accordance with procedure. Record the reaction and negative consequences.
•Because FBDS frequently reacts poorly to AEDs alone, identify brief/frequent movements (FBDS) as seizure-equivalents, measure frequency, and talk about the impact of immunotherapy. Video documentation is beneficial.
➣ Immunotherapy / infusion & peri-procedure nursing
•IV steroid infusions (such as methylprednisolone): provide stomach protection if using steroids for an extended period of time; monitor blood , hyperglycemia, and infection symptoms.
•IVIG: as per local policy, pre-medicate for infusion responses; monitor for thrombotic risks, headaches, and declines in renal function; and make sure you are getting enough water.
•Plasmapheresis: plan vascular access, keep a constant eye on vital signs throughout exchanges, and be alert for bleeding risk, electrolyte imbalances, and hypotension.
•Rituximab/cyclophosphamide: oncology/rheum order—keep an eye out for infusion reactions, infection risk, and neutropenia; take necessary neutropenic precautions.
•The justification for this is because immunotherapies have particular short-term and long-term side effects that need for nurse monitoring.
➣ Airway, ventilation & ICU handover
Prepare for intubation by keeping a bag valve, suction, and airway kit on hand for patients who are hypoventilating or have lost consciousness.
Psychiatric symptoms length, seizure frequency and aetiology, antibody test status (if available), immunotherapies, lines and tubes, nutrition, mobility, current PPE/infection concerns, and family contacts are all items in the ICU handover checklist.
(Justification: many patients have respiratory failure; a smooth transition reduces the time needed for ICU treatments.)
➣Nutrition, skin, mobility — basic but crucial nursing tasks
•Nutrition: monitor intake; initiate enteral feeding as directed by a physician if there is dysphagia or diminished awareness. Electrolyte and weight checks every day.
• Preventing skin and contractures: rotating often, checking pressure points, and passive range of motion if immobilised.
• Bowel and bladder: avoid constipation (risk of opioids and immobility); if retention is suspected, do a bladder scan.
(Justification: extended hospital stays result in problems that lengthen recuperation and raise morbidity.)
➣ Infection prevention & lines
Immunocompromised patients should exercise caution: early removal of superfluous catheters; stringent asepsis for invasive lines. Keep an eye out for fever and its cause (e.g., UTI, pneumonia, line). If necessary, take measures against neutropenia.
(Justification: immunotherapy raises the risk of infection.)
➣ Family involvement, communication & psychosocial care
•Clearly explain the autoimmune underpinnings in plain terms to enable families work together and lessen stigma.
•Be prepared for the following: relapses are possible; recovery is frequently gradual (weeks to months); and cognitive impairments are frequent in the early stages after sickness.
•Give useful assistance, such as contact information for community neurology follow-up, social work, and rehabilitation.
(Justification: family education enhances adherence to treatment and lessens conflict.)
➣ Rehabilitation & discharge planning
•Early referral for rehabilitation: speech, PT, and OT as soon as the patient's health stabilises. Psychiatric follow-up and cognitive rehabilitation should be scheduled.
•Medication reconciliation: note the duration of immunotherapy, AEDs, and psychotropics; caution about driving limitations and returning to work or school.
•For long-term surveillance, follow up with a neurology clinic; three to six months after the sickness, think about getting neuropsych tested.
➣ Sample nursing care plan (NANDA → NOC → NIC style) — ready to copy into charts
→Problem 1: risk of harm from agitation and convulsions.
→Interventions:Pad bed rails, 1:1 supervision, a fast reaction plan, seizure prevention measures, a safe atmosphere, and ongoing monitoring. Justification: lessens shock and enables prompt action.
→Problem 2: inadequate airway clearance as a result of reduced awareness or orofacial dyskinesias.
→Goal: Keep your airway open and your oxygen saturation level high (SpO₂ > 94% unless you have COPD).
→Interventions: Suction, oxygen at the bedside, positioning, getting ready for intubation, and regular respiratory checks. Justification: avoid respiratory failure and aspiration.
→Problem 3: infection risk associated with immunosuppression.
→Goal: No new infections while in the hospital.
→Interventions: Aseptic line approach, temperature and white count monitoring, and prompt removal of intrusive equipment. Justification: Immunotherapy frequently results in infection.
→Problem 4:Nutritional imbalance: less than what the body needs.
→Goal: Preserve or enhance nutritional status (weight gain or stability).
→Interventions: Keep an eye on intake, start enteral feeding if necessary, weigh yourself every day, and see a dietitian. Justification: malnutrition hinders healing.
Notes
Schmitt SE, et al. Extreme delta brush: a unique EEG pattern in adults with anti-NMDAR encephalitis. (EEG pattern & prognostic implications).
StatPearls: Anti-NMDAR encephalitis (concise review of diagnosis & management, 2023).
