Anti-N-Methyl-D-Aspartate Receptor Encephalitis Presenting as Acute Psychosis in a Renal Transplant Recipient Under Chronic Immunosuppression.
Julián David Posada Taborda, Irene Ibarra Muñoz, María Martínez Garrido et al.
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Case in brief
A 38-year-old renal transplant recipient taking tacrolimus and mycophenolate presented with abrupt psychosis, including delusions, auditory hallucinations, and severe agitation. After antipsychotic dose escalation, she developed rigidity, mutism, fever, autonomic instability, and bilateral mydriasis, initially raising concern for neuroleptic malignant syndrome. Persistence after antipsychotic withdrawal and cerebrospinal fluid inflammation prompted further evaluation; anti-GluN1 antibodies were detected in serum and cerebrospinal fluid. She received sequential immunotherapy, and oophorectomy found no teratoma. At 14 months, she had near-complete functional recovery with mild residual attentional impairment.
What made this case unusual
The case combines anti-NMDAR encephalitis with chronic post-transplant immunosuppression and an initial presentation that mimicked primary psychosis and then neuroleptic malignant syndrome. Bilateral mydriasis helped redirect the diagnostic assessment.
Diagnostic / clinical pearl
In a patient with psychosis followed by rigidity and mutism, persistent neurological symptoms after antipsychotic withdrawal and bilateral mydriasis should prompt consideration of anti-NMDAR encephalitis rather than assuming neuroleptic malignant syndrome.