Rationale:
Anti-NMDAR encephalitis during pregnancy is rarely reported, with limited clinical guidance on managing this condition . The challenge lies in balancing effective maternal treatment with minimizing risks to the fetus. This case report provides important insights into the clinical course, management decisions, and outcomes for pregnant patients with anti-NMDAR encephalitis, contributing to the evolving body of evidence to optimize management strategies for both mother and child
Methods:
We present the case of a 22-year-old pregnant woman at 16 weeks and 5 days gestation. Over two weeks, she presented to emergency departments with acute psychiatric symptoms, including agitation, aggression, bizarre behavior, apathy, and two generalized seizures and fever. She was referred to neurology on suspicion of epilepsia partialis continua (EPC). Upon examination, she was febrile (38.8°C), tachycardic, hypertensive (160/80 mmHg), and confused with a positive Brudzinski sign and right upper limb jerky movements. Her neurological status deteriorated, leading to intensive care unit (ICU) admission.
Empirical treatment for suspected meningoencephalitis was initiated, and obstetrics assessed fetal viability. MRI revealed altered signal intensity in the right cerebellar hemisphere, supporting the diagnosis of meningoencephalitis. However, PCR, thyroid function, and ANA tests were negative, narrowing the diagnosis to autoimmune encephalopathy. Treatment with antibiotics was discontinued, and subsequent EEG showed abnormal delta brush patterns, suggesting encephalopathy.
Despite multiple unsuccessful lumbar puncture attempts and an initial lack of improvement, the patient's condition worsened, and anti-NMDAR antibodies were detected in both serum and CSF. IV methylprednisolone and IVIG were administered, but clinical progress remained minimal. Given the patient's poor response, a multidisciplinary team was consulted. On day 45, spontaneous abortion occurred at 21+ weeks gestation, followed by significant clinical improvement, including movement and improved communication. A repeat CSF analysis revealed a high titer of anti-NMDAR antibodies (1:32).
She was subsequently discharged after 18 weeks of hospitalization with no further seizures, on a tapering regimen of levetiracetam, phenytoin, and prednisolone.
In 2017, the patient presented at 13 weeks’ gestation with a headache and a single seizure. No anti-NMDAR antibodies were detected, and her pregnancy proceeded without complications. She delivered a healthy baby and has remained seizure-free, with no recurrence of symptoms up to her last clinic visit in 2023
Results:
This patient has remained in remission for over seven years, with two uneventful pregnancies and no recurrence of anti-NMDAR encephalitis symptoms.
Conclusions:
This case highlights the diagnostic and therapeutic challenges of anti-NMDAR encephalitis during pregnancy. In this case, the disease progressed to seizures, autonomic instability, and respiratory compromise, requiring intensive management. The patient’s lack of response to corticosteroids and IVIG until after spontaneous abortion underscores the potential impact of pregnancy on disease progression and treatment response
Funding: none