Abstracts

Rationale: To describe an unusual presentation of selective impairment of secondary language in N-Methyl-D-Aspartate receptor (NMDA-R) antibody-associated autoimmune encephalitis.


Methods: Clinical case study presentation.

Results: A 30-year-old native Ki’che and fluently Spanish speaking female with no known past medical history who recently immigrated from Guatemala was diagnosed with left temporal epilepsy after suffering two convulsions. Speech production was slow at that time, which was ascribed to a post-ictal state. She was discharged with carbamazepine. Three weeks later, she presented to her follow-up appointment reporting an inability to speak for at least 8 days prior. She reported no further convulsions or any other change in her neurological status and was compliant with carbamazepine. No medical care had been sought in the interim as her family members were still able to communicate with her in a limited way in Ki’che, but she was entirely unable to comprehend or speak Spanish. EEG showed continuous left frontotemporal slowing, but no ictal patterns (Fig. 1). Contrast-enhanced MRI showed subtle left temporal lobe edema (Fig. 2) and lumbar puncture revealed mild lymphocytic pleocytosis. Extensive laboratory workup ruled out infectious, malignant, or toxic etiologies. However, the patient tested positive for CSF NMDA-R antibodies. Empiric acyclovir along with pulse-dose steroids were initiated, and levetiracetam was added. After three days, the patient began to show intermittent comprehension in Spanish and a prolonged steroid taper was prescribed upon discharge. At 3-month follow-up, she fully regained Spanish language fluency, and had self-tapered carbamazepine without recurrence of seizures.


Conclusions: Temporal lobe seizures in multilingual patients can present with a vast heterogeneity of language impairment, and little is known about the specific underlying mechanisms, or why the primary language is often better preserved (1). While isolated aphasia has previously been described in temporal lobe seizures (2-4), this is the first case to our knowledge of aphasia affecting primarily the secondary language in temporal lobe seizures from autoimmune encephalitis with full recovery after steroid therapy. This case highlights both the importance and challenge of early diagnostics and intervention, especially in patient populations who are recent immigrants, where language impairment and poor access to health care can have even more devastating consequences.


Funding: No relevant sources of funding to report.