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Authors’ reply

Published online by Cambridge University Press:  02 January 2018

Helen Barry
Affiliation:
Department of Psychiatry, Royal College of Surgeons in Ireland, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland. Email: helenbarry@rcsi.ie
Kieran Murphy
Affiliation:
Department of Psychiatry, Royal College of Surgeons in Ireland, RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
David Cotter
Affiliation:
Department of Psychiatry, Royal College of Surgeons in Ireland, RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
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Abstract

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Columns
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Copyright © Royal College of Psychiatrists, 2012 

We thank Dr Moran for highlighting the importance of immunologically mediated encephalitis when considering differential diagnoses for atypical psychosis. Dr Moran suggests that the aetiological association of anti-NMDA receptor encephalitis with ovarian neoplasms, in particular teratomas, was perhaps understated in our case series of four patients, where we reported ovarian pathology (a dermoid cyst) in one patient. Reference Barry, Hardiman, Healy, Keogan, Moroney and Molnar1 By contrast, Dalmau et al's original series of 100 cases identified ovarian teratomas in 54 of the 58 cases with ovarian pathology and early removal of such tumours was associated with better outcomes. Reference Dalmau, Gleichman, Hughes, Rossi, Peng and Lai2 However, more recent studies have not observed such high rates of ovarian pathology. Reference Florance, Davis, Lam, Szperka, Zhou and Ahmad3,Reference Irani, Bera, Waters, Zuliani, Maxwell and Zandi4 In a series of 44 patients with anti-NMDA receptor encephalitis, Irani and colleagues found tumours in 9 patients of which 8 cases were ovarian teratomas. Furthermore, 25% of cases overall were male. In keeping with Dalmau and colleagues, the identification and removal of an ovarian tumour was associated with a better outcome, Reference Dalmau, Gleichman, Hughes, Rossi, Peng and Lai2 although the best outcome was predicted by adequate immunotherapy during initial illness. Reference Irani, Bera, Waters, Zuliani, Maxwell and Zandi4

As noted previously, it is still unclear whether there is a purely psychiatric presentation to this disorder. However, the constellation of symptoms including some or all of catatonia, dyskinesias and seizures with psychosis certainly warrants anti-NMDA receptor antibody testing. We agree with Dr Moran that future studies are required to determine whether routine screening for NMDA receptor antibodies is indicated for atypical presentations, treatment-resistant cases and first-onset psychosis.

References

1 Barry, H, Hardiman, O, Healy, DG, Keogan, M, Moroney, J, Molnar, PP, et al. Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis. Br J Psychiatry 2011; 199: 508–9.Google Scholar
2 Dalmau, J, Gleichman, AJ, Hughes, EG, Rossi, JE, Peng, X, Lai, M, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol 2008; 7: 1091–8.Google Scholar
3 Florance, NR, Davis, RL, Lam, C, Szperka, C, Zhou, L, Ahmad, S, et al. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis in children and adolescents. Ann Neurol 2009; 66: 11–8.Google Scholar
4 Irani, SR, Bera, K, Waters, P, Zuliani, L, Maxwell, S, Zandi, MS, et al. N-methyl-D-aspartate antibody encephalitis: temporal progression of clinical and paraclinical observations in a predominantly non-paraneoplastic disorder of both sexes. Brain 2010; 133(Pt 6): 1655–67.CrossRefGoogle Scholar
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