Autoimmune encephalitis — the immune system attacking brain proteins — can cause psychosis, seizures, and coma. It is treatable but frequently mistaken for psychiatric illness. Dr. Anand Karnam explains the clues and the importance of early diagnosis.
Key Points
- Autoimmune encephalitis presents with rapid-onset psychiatric symptoms, seizures, movement disorders, and reduced consciousness.
- Anti-NMDA receptor encephalitis is the most common type — most often affects young women and can follow ovarian teratoma.
- Diagnosis requires antibody testing in both CSF and blood — serum alone misses some cases.
- EEG shows characteristic 'extreme delta brush' pattern in anti-NMDA encephalitis.
- Rapid immunotherapy (steroids, IVIG, plasma exchange) and tumour removal (if applicable) are life-saving.
80%
of anti-NMDA encephalitis patients recover with immunotherapy
Source: Lancet Neurology
50%
of cases have an underlying ovarian teratoma — removal accelerates recovery
Source: NCBI
4–6 weeks
typical time to significant clinical improvement after starting immunotherapy
Source: NCBI
"Autoimmune encephalitis presents like acute psychosis — agitation, hallucinations, bizarre behaviour — and gets admitted to psychiatry wards. The neurologist who thinks of this diagnosis and tests for antibodies can transform the outcome from permanent brain damage to full recovery."
Autoimmune encephalitis (AE) — inflammation of the brain caused by antibodies against neuronal surface proteins — was only characterised and systematically described from 2007 onwards, but has rapidly become one of the most important causes of new-onset encephalopathy, especially in young people. The antibodies impair neuronal function and cause the clinical syndrome. The most common and paradigmatic form is anti-NMDA receptor encephalitis, but dozens of antibody-specific variants exist. AE is frequently misdiagnosed as psychiatric illness for weeks to months — a dangerous delay that worsens outcomes.
Anti-NMDA Receptor Encephalitis — Stages of Presentation
This condition disproportionately affects young women (but also men and children). The clinical course progresses through characteristic stages: Prodrome (1–2 weeks): Flu-like illness — headache, fever, fatigue. Psychiatric phase (2–4 weeks): Anxiety, agitation, paranoia, hallucinations (visual and auditory), behavioural change, insomnia. Patients are referred to psychiatry and treated with antipsychotics — which have minimal effect. Neurological phase: Seizures; abnormal involuntary movements (orofacial dyskinesias — chewing, grinding movements; limb choreiform movements); speech disorganisation and then mutism; autonomic instability (heart rate and BP fluctuations); progressive loss of consciousness. This is an ICU emergency.
Red Flags That Should Prompt AE Testing
New-onset psychiatric symptoms in a previously well young person with no psychiatric history; rapid deterioration over weeks; fever with psychiatric symptoms; seizures alongside psychiatric symptoms; orofacial dyskinesias; treatment-resistant psychiatric presentation; CSF pleocytosis (white cells — unusual in primary psychiatric illness).
Treatment
First-line: IV methylprednisolone + IV immunoglobulin (IVIG) or plasma exchange. Remove underlying tumour if present (30% of anti-NMDA encephalitis in adult women is associated with ovarian teratoma — removal is part of treatment). Second-line for non-responders: rituximab, cyclophosphamide. Prognosis is good with early treatment — most patients make substantial recovery. Delayed diagnosis worsens outcomes. Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.
Dr. Anand Karnam
DrNB Neurology · Sri Anand CNC, Chanda Nagar Hyderabad · Sri Anand Child and Neuro Center
DrNB-qualified Neurologist, Fellow of the World Headache Society (FWHS), and Headache Specialist with 12+ years of experience treating epilepsy, stroke, migraine, and movement disorders. Practices at Sri Anand Child and Neuro Center, Chanda Nagar, Hyderabad.
References & Sources
- 1.Autoimmune Encephalitis — NCBI StatPearls — NCBI StatPearls
- 2.Encephalitis — NIH MedlinePlus — NIH MedlinePlus
- 3.Encephalitis — NHS — NHS UK
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