ECT for Autoimmune Encephalitis: Case Report from Denmark
Out on PubMed, from clinicians in Aarhus, Denmark, is this case report:
[ECT in autoimmune encephalitis].
Ugeskr Laeger. 2021 Jan 18;183(3):V09200703.PMID: 33491641 Danish.
The abstract is copied below:
In this case report, a 27-year-old male presented at a department of neurology with postherpetic anti-N-methyl-d-aspartate (NMDA) receptor autoimmune encephalitis. The patient was psychotic and exhibited symptoms of akinetic and excited catatonia. He was mechanical restrained for a total of 46 days due to violent behaviour. He was treated with olanzapine and lorazepam up to 15 mg/day without effect on catatonic and behavioural symptoms. ECT was initiated, and the patient received a total of 16 treatments. He responded well to the treatment, and the violent behaviour resolved completely after the first treatment. ECT should be considered for catatonia in anti-NMDA-receptor autoimmune encephalitis.
The pdf is here. (in Danish)
This patient had herpes encephalitis treated with acyclovir and complicated by NMDAR autoimmune encephalitis. Cerebral edema required decompressive craniectomy, with placement of a metal plate. He had severe amnesia and apraxia. Catatonia and psychosis developed while he was in rehab; plasmapheresis, steroids, rituximab, olanzapine and lorazepam (up to 15 mg/day) were ineffective. The ECT course consisted of 3 "en bloc" (does this means multiple stimuli at the same session or just daily?) treatments, 9 additional standard inpatient treatments, and 4 outpatient continuation treatments. No other details of the ECT are given. The abstract notes no further violent behavior after the first treatment; the text says that no restraints were needed after ECT #4 (46 days total in restraints). [Presumably, this is also another case of safe ECT with a metal skull plate in place.] At six months follow up, he had residual cognitive deficits, but was improving.
So, again, what we've got here is failure to improve with multiple, fairly drastic treatments (plasmapheresis, high-dose steroids, immunotherapy), not to mention the psychiatric medications; ECT is finally tried, and the response is dramatic.
At some point, with enough similar anecdotal evidence, perhaps ECT will be considered sooner in the treatment algorithm. On the other hand, Anthony Fauci did say on Jan. 25th on CNN, that "to be ruled by anecdote is folly."
[The pdf to the catatonia article referred to by Dr. Fink in his comment is here.]
The below comment is from Dr. Max Fink:
ReplyDeleteECT for autoimmune encephalitis and delirious mania: Feb 15, 2021
In this ultimately successful treatment of delirious mania secondary to herpes simplex encephalitis the clinicians achieved resolution with ECT, and en bloc ECT at that. DM was recognized as a treatable form of catatonia in 1990s. Autoimmune encephalitis was recognized as treatable by ECT more recently (the NMDAR form was first recognized in 2007). This recognition is documented in a recent report in JECT (Expanding the Catatonia Tent, Max Fink, JECT, in press)
As more forms of catatonia are recognized and ECT as the effective treatment, more seriously ill will be salvaged. ECT should be taken out of psychiatry which is increasingly a psychological discipline and assumed as a medical discipline.
I would like to know more of the professional dynamics in coming to use ECT. How did they arrive at ECT?
Max Fink