Management of anti-NMDAr encephalitis in the Intensive Care Unit: a case report

Background Anti-NMDA receptor encephalitis has become a growing concern in young people. It usually manifests with rapid psychiatric and neurological symptoms. ICU admission is frequent, requiring a multidisciplinary approach for informed decision-making. While first-line treatments are standardized, there is no clear guideline for when to escalate to ovarian surgery or second-line immunotherapy, though early intervention is often recommended. Case Presentation A 31-year-old woman presented with a one-week history ofanxiety and insomnia. She developed speech dysfunction and disorganized behaviour. Normal diagnostic tests were followed by cerebrospinal fluid analysis showing lymphocytic pleocytosis and mildly elevated proteins. Her condition deteriorated with generalized seizures and decreased level of consciousness, requiring ICU admission and mechanical ventilation. Empirical immunotherapy was initiated, and right oophorectomy revealed a mature cystic teratoma. NMDAR antibodies in CSF analysis confirmed the diagnosis. Rituximab was administered, leading to full recovery within nine months. Discussion Anti-NMDAR encephalitis should be considered in young patients with acute psychiatric symptoms. Rapid diagnosis can be challenging due to overlapping symptoms with infections and psychiatric disorders. EEG and CSF analysis are pivotal for diagnosis. Ovarian teratomas, found in some cases, may accelerate recovery post-removal. Treatment involves early first-line immunotherapy and second-line treatments like rituximab, particularly in severe or refractory cases. Conclusion Early identification and treatment of anti-NMDAR encephalitis are crucial for recovery. Multidisciplinary care and timely immunotherapy, along with surgical intervention for teratomas, offer the best outcomes. More research is needed to establish clearer guidelines for second and third-line therapies.