Anti-NMDA Receptor Encephalitis Medical Slides

Present the stereotyped phases: (1) viral-like prodrome (fever, headache), (2) psychiatric symptoms (psychosis, agitation, paranoia — often leading to initial psychiatric admission), (3) neurological deterioration (seizures, movement disorders — orofacial dyskinesias are characteristic, decreased consciousness), (4) autonomic instability and hypoventilation requiring ICU, (5) slow recovery over weeks to months. This sequential pattern is a key diagnostic clue — the evolution from "psychiatric" to "neurological" should trigger antibody testing.

Present the "extreme delta brush" pattern: continuous rhythmic delta activity (1-3 Hz) with superimposed beta frequency bursts riding on each delta wave, seen in 30% of cases and highly specific for anti-NMDA receptor encephalitis. Also show generalized slowing (most common EEG finding) and electrographic seizures. Emphasize that EEG monitoring is essential because subclinical seizures are common, and the extreme delta brush pattern can appear before CSF antibodies are resulted.

Present a staged approach: tumor removal is the single most important intervention (if teratoma found). First-line immunotherapy: IV methylprednisolone 1g/day × 5 days + IVIG 0.4 g/kg/day × 5 days (or PLEX). Assess at 2 weeks — if no improvement, escalate to second-line: rituximab 375 mg/m² × 4 weekly doses + cyclophosphamide. Reference the Titulaer 2013 observational study showing 53% responded to first-line, 97% of second-line responders improved, and 12% relapse rate (reduced with second-line therapy).