Psych Vivas · Consultation-liaison psychiatry
Autoimmune encephalitis and organic psychosis — structured clinical viva
Fellowship viva on AE red flags, Graus/Pollak frameworks, MRI/EEG/CSF/Abs, first-line immunotherapy, teratoma, and CL partnership.
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Interpretation
Reveal interpretationShowHide
Reject primary schizophrenia as a premature label. Nine-day multistage course with mutism, dyskinesias, and fluctuating alertness is a textbook AE red-flag package despite normal MRI.[1][6]
Frameworks. Map to Graus possible/probable AE and Pollak possible/probable autoimmune psychosis. Treatment can proceed for probable disease while Abs pend.[2][4]
Work-up. EEG; LP with infection panel as indicated; paired serum–CSF cell-based neuronal Abs; pelvic imaging for teratoma; continuous monitoring for seizures/autonomic/hypoventilation risk.[5][6]
Treatment. First-line immunotherapy (steroids ± IVIG ± PLEX); second-line rituximab/cyclophosphamide if needed; resect teratoma if present. Early care improves outcomes (Titulaer).[3][5]
Psychiatry role. Benzodiazepines for catatonia/agitation; cautious psychotropic bridge; capacity/legal pathway for investigation; family explanation; do not own solo immunosuppression without neurology.[4][5]
Answer the team. "Normal MRI does not exclude anti-NMDAR encephalitis. LP is high-yield and indicated. This may be a treatable autoimmune encephalitis — antipsychotics alone are insufficient."[6][1]
References6ShowHide
- [1]Herken J, Prüss H Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients Front Psychiatry, 2017.PMID 28261116
- [2]Graus F, Titulaer MJ, Balu R, et al. A clinical approach to diagnosis of autoimmune encephalitis Lancet Neurol, 2016.PMID 26906964
- [3]Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study Lancet Neurol, 2013.PMID 23290630
- [4]Pollak TA, Lennox BR, Müller S, et al. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin Lancet Psychiatry, 2020.PMID 31669058
- [5]Abboud H, Probasco JC, Irani S, et al. Autoimmune encephalitis: proposed best practice recommendations for diagnosis and acute management J Neurol Neurosurg Psychiatry, 2021.PMID 33649022
- [6]Dalmau J, Graus F Antibody-Mediated Encephalitis N Engl J Med, 2018.PMID 29490181