Abstract Introduction Anti−NMDA receptor encephalitis is a rare autoimmune disorder characterized by autonomic instability and diverse neuropsychiatric manifestations, with an estimated incidence of 1 per 1.5 million individuals annually. Although its coexistence with tuberculosis is exceptionally rare, clinicians should consider this association in patients presenting with unusual clinical features. Case Description We report the case of a 20−year−old, Filipino, female who presented with a two-week history of generalized throbbing headache associated with anhedonia, agitation, hallucinations and suicidal ideation. She was initially referred to a psychiatric facility and managed as a case of severe depressive episode with psychotic features, for which sertraline and olanzapine were started. Due to the persistence of symptoms, she was admitted to our institution. On the 15th hospital day, the patient developed status epilepticus, necessitating intubation and referral to the Pulmonary Medicine service. A chest radiograph revealed right lower lobe pneumonia hence, broad spectrum antibiotics were initiated. Cerebrospinal fluid analysis showed positive anti−NMDA receptor IgG, confirmed by serum testing. She received intravenous methylprednisolone pulse therapy followed by intravenous immunoglobulin (IVIg). Cranial MRI was unremarkable while EEG showed mild diffuse cerebral dysfunction. Even after further immunotherapy with IVIg and rituximab, seizures persisted despite maximal doses of midazolam, levetiracetam, valproic acid, and phenytoin. Due to intractable seizures, the patient remained ventilator−dependent and a tracheostomy was performed. QuantiFERON-TB Gold tests were done twice and yielded indeterminate results, prompting a chest CT scan that revealed bilateral lower lobe pulmonary tuberculosis with endobronchial spread. Anti−Koch’s therapy was initiated and notably, seizure episodes resolved completely by the third day of treatment. The patient was subsequently weaned off mechanical ventilation, discharged, underwent decannulation at the outpatient department and currently remains in good general condition. Discussion This case highlights the rare coexistence of anti NMDA receptor encephalitis and pulmonary tuberculosis, emphasizing the need to consider infectious etiologies in patients with neuropsychiatric symptoms and refractory seizures. Anti NMDA receptor encephalitis involves antibodies targeting NMDA (N−methyl−D−aspartate) receptors, causing central nervous system inflammation. Tuberculosis infection may provoke immune dysregulation that promotes autoimmunity by disrupting the intracranial immune environment, damaging neural tissue, and compromising the blood-brain barrier. This allows peripheral NMDA receptor antigens to enter the CNS, triggering antibody production. The interaction between infection and autoimmunity suggests a potential immunopathogenic link that warrants further study. This abstract is funded by: None
Delgado et al. (Fri,) studied this question.
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