Anti-Leucine-Rich Glioma-Inactivated 1 (Anti-LGI 1) Limbic Encephalitis and New-Onset Psychosis: A Case Report

Abstract

Anti-leucine-rich glioma-inactivated 1 limbic encephalitis (Anti-LGI 1 LE) is a subtype of autoimmune encephalitis (AE) and the most common cause of limbic encephalitis (LE). Clinically, it can have an acute to sub-acute onset of confusion and cognitive impairment, facial-brachial dystonic seizures (FDBS), and psychiatric disturbances. The clinical manifestations are varied, and its diagnosis requires high clinical suspicion to avoid delay in the treatment. When patients manifest mostly psychiatric symptoms, the disease may not be immediately recognized. We aim to report a case of Anti-LGI 1 LE in which the patient presented acute psychotic symptoms and was initially diagnosed with unspecified psychosis. We present a case of a patient with sub-acute behavioral changes, short-term memory loss, and insomnia who was brought to the emergency department after a sudden episode of disorganized behavior and speech. On medical examination, the patient presented persecutory delusions and indirect signs of auditory hallucinations. An initial diagnosis of unspecified psychosis was performed. Investigations revealed right temporal epileptiform activity in the electroencephalogram (EEG), abnormal bilateral hyperintensities in the temporal lobes in the brain magnetic resonance imaging (MRI), and a positive titer of anti-LGI 1 antibodies (Abs) in serum and cerebrospinal fluid (CSF), leading to a diagnosis of anti-LGI 1 LE. The patient was treated with intravenous (IV) steroids and immunoglobulin and later with IV rituximab. In patients that predominantly present with psychotic and cognitive disorders the diagnosis of anti-LGI 1 LE can be delayed predisposing them to a poorer prognosis (permanent cognitive impairment - especially short-term memory loss - and persistent seizures). It is necessary to be aware of this diagnosis when evaluating acute to sub-acute psychiatric illness developing with cognitive impairment (specially with memory loss) to avoid diagnosis delays and long-term sequelae.

Keywords: anti-leucine-rich glioma-inactivated 1 limbic encephalitis; autoimmune encephalitis; liaison psychiatry; limbic encephalitis; psychosis.

Figure 1. Electroencephalogram - Frame 1

Right temporal epileptiform activity, as highlighted with arrows

Figure 2. Electroencephalogram - Frame 2

Right temporal epileptiform activity, as highlighted with arrows

Figure 3. Electroencephalogram - Frame 3

Right temporal epileptiform activity, as highlighted with arrows

Figure 4. Electroencephalogram - Frame 4

Right temporal epileptiform activity, as highlighted with arrows

Figure 5. Brain MRI showing bilateral hyperintensities in the temporal lobes