Postpartum Anti-N-methyl-D-aspartate Receptor Encephalitis: A Case Report and Literature Review

Abstract

We describe a 24-year-old woman with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis that developed 3 weeks after normal delivery. She was treated with methylprednisolone, intravenous immunoglobulin, and plasmapheresis, in addition to teratoma excision. However, her recovery was slow, and dysmnesia and mental juvenility persisted even two years after onset. To date, five patients with postpartum anti-NMDAR encephalitis have been reported. All of those patients showed psychotic symptoms and were suspected of having postpartum psychosis in the early period of the encephalitis. Changes in hormonal factors, modification of immune tolerance, or retrograde infection of the ovary may be contributing factors for postpartum anti-NMDAR encephalitis.

Figure 1.

The clinical course of the patient. SIMV: synchronized intermittent mandatory ventilation, PS: pressure support, CPAP: continuous positive airway pressure, IVIg: intravenous immunoglobulin, PE: plasma exchange, DFPP: double filtration plasmapheresis, mPSL: methylprednisolone, DVT: deep vein thrombosis

Figure 2.

Electroencephalogram of the patient. Diffuse beta activity superimposed on frontally dominant high-voltage rhythmic delta bursts was observed.

Figure 3.

Brain magnetic resonance image (MRI) of the patient (FLAIR image, axial view). (A) MRI performed at 1 month after onset. High signal intensity and slight swelling were seen in the bilateral medial temporal lobes. (B) MRI performed at 2 years after onset. Abnormal signal intensity in the bilateral medial temporal lobes disappeared without brain atrophy.

Figure 4.

The radiological and pathological findings of the ovarian teratoma. (A) Computed tomography of the pelvis showed a cystic tumor (1.5 cm in maximal diameter) with small calcifications adjacent to the right ovary. (B) Gross pathology of the encapsulated ovarian teratoma containing hair.