MYSTERY CASE PRESENTATIONS – RESIDENTS
PARANEOPLASTIC ANTI-NMDAR ENCEPHALITIS: MYSTERY WITH AN OVARIAN TERATOMA TWIST Asad Mussarat, Catherine Loehr, Michelle Livitz, Will Gibson, Allison Pinner; LSU Health Science Center, Department of Internal Medicine, New Orleans, LA.
Introduction: Anti-N-methyl D-aspartate receptor (NMDAR) encephalitis is a potentially lethal autoimmune encephalitis in young adults. It typically begins with a viral-like prodrome, followed by neuropsychiatric symptoms and is diagnosed by detecting autoantibodies in cerebrospinal fluid (CSF). Since 2007, research has linked anti-NMDAR encephalitis with ovarian teratomas as a paraneoplastic syndrome. We present a case of a young woman whose encephalitis course takes an unexpected turn. Case: A 25-year-old woman without a past medical history developed headaches, fevers, vomiting, and a seizure after five days. Her partner witnessed another seizure involving jerking movements. Despite normal physical exams, a negative electroencephalogram, and a brain magnetic resonance revealed bilateral temporal edema. CSF analysis showed increased red blood cells and lymphocytic pleocytosis, raising suspicion of herpes simplex virus (HSV) encephalitis. She initially improved on acyclovir and steroids but became encephalopathic a week later, with emotional outbursts. Autonomic instability led to an intensive care unit admission, as she needed to be intubated. HSV tests were negative, but a
computed tomography scan of her abdomen and pelvis revealed a right ovarian dermoid cyst, which was confirmed surgically as an ovarian teratoma. CSF analysis detected anti-NMDA receptor antibodies, confirming anti-NMDAR encephalitis. After treatment with IVIG, steroids, cyclophosphamide, and plasmapheresis, she improved but required long- term rehabilitation, remaining far from her baseline. Discussion: Research indicates a significant link between anti-NMDAR encephalitis and ovarian teratomas. It is believed that neuronal tissue in the teratoma triggers an immune response, producing autoantibodies that mistakenly target NMDA receptors in the brain. This paraneoplastic syndrome results in autoimmune destruction and severe neuropsychiatric symptoms, drastically affecting quality of life. Despite its rare incidence, autoimmune encephalitis should be considered in young encephalopathic patients, particularly women. Early surgical resection of ovarian tumors is crucial in anti-NMDAR encephalitis, as prolonged autoimmune activity worsens its prognosis. Recognizing this paraneoplastic association enables more effective interventions and improved outcomes.
KOMMERELL DIVERTICULUM: A RARE VASCULAR ANOMALY CAUSING NONSPECIFIC CHEST PAIN Neha Bapatla, Jacques F. Ancelet, Stephen C. Lim; Tulane University, New Orleans, LA.
Introduction: Chest pain is one of the most common symptoms for which individuals seek evaluation and treatment. While cardiopulmonary and gastrointestinal causes of chest pain tend to follow familiar patterns of presentation, vascular etiologies are often missed unless overtly symptomatic and thus present a challenge to diagnosticians. Case: 28-year-old male presented with chest pain and new dysphagia. He reported a sharp substernal chest pain radiating intermittently to the bilateral
upper and lower extremities. Pain was rated at a 10/10, present at rest, and exacerbated when laying down. His chest pain had been recurring over the past decade. Notably, the patient reported new dysphagia over the past year. He experienced dysphagia primarily to solids although intermittently experienced a globus sensation with liquids as well. He endorsed subjective weight loss due to an inability to eat or drink with associated diffuse abdominal discomfort--although he was seen eating a sandwich in the emergency room without difficulty. The 14
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