Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Case Description: A 21-year-old female with a history of asthma presented to the emergency department (ED) with restlessness, anxiety, and loss of appetite shortly after returning from a trip to France, where she and her boyfriend ended their relationship. Her initial evaluation, including unremarkable laboratory results, led to the attribution of her symptoms to anxiety from life stressors. She was treated with supportive measures in the ED and prescribed Xanax by her primary care physician at follow-up. Six days later, the patient returned to the ED with hallucinations and panic attacks. Again, laboratory results were unremarkable, and she was diagnosed with acute psychosis, managed with Ativan and Haldol. She was subsequently transferred to a behavioral health facility but returned to the ED with tachycardia. Further evaluation, including EEG, revealed findings concerning for encephalitis, prompting initiation of acyclovir. She was transferred to our facility, where long-term electroencephalographic monitoring (LTM EEG) revealed subclinical seizure activity and diffuse background slowing with extreme delta brushes, consistent with anti-NMDA receptor encephalitis. Lumbar puncture demonstrated lymphocytic pleocytosis, supporting the diagnosis. The patient was started on solumedrol for suspected anti-NMDA receptor encephalitis. A CT scan identified a large left adnexal mass. Surgical intervention, including exploratory laparotomy, left oophorectomy, and right cystectomy, revealed an immature teratoma. Tumor markers were notable for mildly elevated CA-125 and CA 19-9. Postoperatively, the patient underwent six sessions of plasmapheresis, followed by her first dose of rituximab. She was discharged on an anti-epileptic regimen (Vimpat and Keppra) with follow-up appointments scheduled with an epileptologist, neuroimmunologist, oncologist, and behavioral health provider. Discussion/Conclusion: This case highlights the diagnostic challenges and biases often faced by women presenting with complex symptomatology. Initially, the patient’s physical exam revealed catatonia and psychosis, findings that were initially misattributed to anxiety secondary to life stressors. This misdiagnosis contributed to delays in the recognition and treatment of anti-NMDA receptor encephalitis. However, with timely intervention including immunotherapy, plasmapheresis, and surgical resection of her immature teratoma, the patient demonstrated significant improvement in her mentation and physical exam, underscoring the reversibility of her condition when appropriately managed. This case exemplifies the importance of considering organic causes for symptoms that may appear psychological, particularly in women, who are disproportionately affected by diagnostic overshadowing. Prior studies have documented similar disparities; for instance, nearly 50% of women with endometriosis report diagnostic delays, often due to initial misdiagnosis with mental health conditions. This case emphasizes the need for a thorough and unbiased diagnostic approach to avoid overlooking potentially life-threatening conditions. By challenging these biases, medical practitioners can ensure timely and accurate care, ultimately improving patient outcomes.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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