Catatonia in Anti-NMDA Receptor Encephalitis: a Case Series and Approach to Improve Outcomes With ECT

Out on PubMed, from clinicians at Duke, is this case series:

Catatonia in anti-NMDA receptor encephalitis: a case series and approach to improve outcomes with electroconvulsive therapy.

Kraiter FG, May DT, Slauer RD, Abburi N, Eckstein C, Shah S, Komisar JR, Feigal JP.BMJ Neurol Open. 2024 Nov 12;6(2):e000812. doi: 10.1136/bmjno-2024-000812. eCollection 2024. PMID: 39564516

The abstract is copied below:

Background: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has been recognised to present with the syndrome of catatonia. In severe cases dysautonomia is representative of malignant catatonia. The treatment with benzodiazepines (BZDs) and electroconvulsive therapy (ECT) may decrease morbidity and mortality in patients presenting with anti-NMDA receptor encephalitis and catatonia.

Methods: This is a retrospective case series of eight patients with anti-NMDA receptor encephalitis treated with ECT. We use clinical prediction scores (Clinical Assessment Scale for Autoimmune Encephalitis [CASE] and anti-NMDAR Encephalitis One-Year Functional Status scores) to compare expected outcomes and observed outcomes.

Results: CASE scores in our group ranged between 5 and 19, with a mean score of 13.8 (median 15.5). NEOS scores ranged from 2 to 4, with a mean and median of 3. Of the eight patients, six had a favourable modified Rankin Score (0-2) at a follow-up of 8 to 12 months. Patients received an average of 29.9 ECT treatments in total.

Conclusions: Based on clinical prediction scores, this cohort had better than expected functional outcomes. We discuss the use of BZDs and ECT in these cases and propose a treatment algorithm for patients who present with catatonic syndrome in anti-NMDA receptor encephalitis.

Keywords: CLINICAL NEUROLOGY; ELECTRICAL STIMULATION; NEUROIMMUNOLOGY; NMDA; PSYCHIATRY.

The report is here.

And from the text:








This is a very thoughtfully presented case series that is an important addition to the literature on the treatment of anti-NMDAR encephalitis.
The authors discuss the timing of ECT and state:

ECT may have provided benefit to decrease morbidity as an adjuvant to immunotherapy in patients exhibiting symptoms of malignant catatonia.

This is likely true, but what about the corollary:
immunotherapy as an adjuvant to ECT?
OpenEvidence says that primary immunotherapy is effective in only 53% of cases. So, what about ECT as a first-line therapy, without waiting for the development of catatonia? (Of course, teratomas must be removed).
Kudos to these authors for a fascinating contribution to the catatonia literature.



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