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2015 ; 172
(9
): 901-8
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Autoimmune Encephalitis in Postpartum Psychosis
#MMPMID26183699
Bergink V
; Armangue T
; Titulaer MJ
; Markx S
; Dalmau J
; Kushner SA
Am J Psychiatry
2015[Sep]; 172
(9
): 901-8
PMID26183699
show ga
OBJECTIVE: Significant immunological alterations have been observed in women with
first-onset affective psychosis during the postpartum period. Recent studies have
highlighted the possibility that a subset of patients with first-onset severe
psychiatric episodes might suffer from undiagnosed autoimmune encephalitis.
Therefore, the authors performed a three-step immunohistochemistry-based
screening for CNS autoantibodies in a large cohort of patients with postpartum
psychosis and matched postpartum comparison subjects. METHOD: Ninety-six
consecutive patients with postpartum psychosis and 64 healthy postpartum women
were included. Screening for antibodies in patient serum was performed using
immunohistochemistry. Samples showing any staining were further examined by
immunocytochemistry using live hippocampal neurons and cell-based assays to test
for anti-N-methyl-d-aspartate (NMDA) receptor antibodies. Cell-based assays for
all other known CNS antigens were performed in those samples with
immunocytochemistry labeling but negative for NMDA receptor antibodies. RESULTS:
Four patients (4%) with neuropil labeling suggestive for extracellular antigen
reactivity were identified. Serum samples from all four patients showed clear
extracellular labeling of live hippocampal neurons. Two women had the specific
staining pattern characteristic for anti-NMDA receptor antibody positivity, which
was confirmed by cell-based assays. Neither patient with anti-NMDA receptor
antibody positivity had evidence of an ovarian teratoma. The other two patients
tested negative by cell-based assays for all known CNS antigens. None of the
matched postpartum comparison subjects had confirmed neuronal surface antibodies.
The two patients with anti-NMDA receptor antibodies both showed extrapyramidal
symptoms following initiation of treatment with low-dose haloperidol.
CONCLUSIONS: In patients with acute psychosis during the postpartum period,
systematic screening for anti-NMDA receptor autoantibodies should be considered.
The acute onset of severe atypical psychiatric symptoms in young female patients
should raise the index of suspicion for anti-NMDA receptor encephalitis,
particularly in the setting of neurological symptoms, including extrapyramidal
side effects of antipsychotic treatment.
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