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Clinical Atlas Prestige · Evidence-first

Psych VivasConsultation-liaison psychiatry

Psych Vivas · Consultation-liaison psychiatry

Autoimmune encephalitis and organic psychosis — structured clinical viva

Fellowship viva on AE red flags, Graus/Pollak frameworks, MRI/EEG/CSF/Abs, first-line immunotherapy, teratoma, and CL partnership.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar on call. A 25-year-old woman with first presentation of psychosis over 9 days now has mutism, orofacial dyskinesias, and fluctuating alertness. MRI is normal. The medical team asks whether this is 'just schizophrenia' and whether LP is worth the risk. Discuss red flags, differential, investigation hierarchy including antibodies, immunotherapy principles, tumour search, symptomatic care, and how you answer the team.

Interpretation

Reveal interpretation

Reject primary schizophrenia as a premature label. Nine-day multistage course with mutism, dyskinesias, and fluctuating alertness is a textbook AE red-flag package despite normal MRI.[1][6]

Frameworks. Map to Graus possible/probable AE and Pollak possible/probable autoimmune psychosis. Treatment can proceed for probable disease while Abs pend.[2][4]

Work-up. EEG; LP with infection panel as indicated; paired serum–CSF cell-based neuronal Abs; pelvic imaging for teratoma; continuous monitoring for seizures/autonomic/hypoventilation risk.[5][6]

Treatment. First-line immunotherapy (steroids ± IVIG ± PLEX); second-line rituximab/cyclophosphamide if needed; resect teratoma if present. Early care improves outcomes (Titulaer).[3][5]

Psychiatry role. Benzodiazepines for catatonia/agitation; cautious psychotropic bridge; capacity/legal pathway for investigation; family explanation; do not own solo immunosuppression without neurology.[4][5]

Answer the team. "Normal MRI does not exclude anti-NMDAR encephalitis. LP is high-yield and indicated. This may be a treatable autoimmune encephalitis — antipsychotics alone are insufficient."[6][1]

Key points

Normal MRI is not reassurance

Anti-NMDAR disease often has normal imaging.

Paired CSF testing

Cell-based assays with CSF context beat serum-only shortcuts.

Treat probable disease

Do not wait forever for serology when criteria are met.
[2] [3] [5]

References

  1. [1]Herken J, Prüss H Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients Front Psychiatry, 2017.PMID 28261116
  2. [2]Graus F, Titulaer MJ, Balu R, et al. A clinical approach to diagnosis of autoimmune encephalitis Lancet Neurol, 2016.PMID 26906964
  3. [3]Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study Lancet Neurol, 2013.PMID 23290630
  4. [4]Pollak TA, Lennox BR, Müller S, et al. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin Lancet Psychiatry, 2020.PMID 31669058
  5. [5]Abboud H, Probasco JC, Irani S, et al. Autoimmune encephalitis: proposed best practice recommendations for diagnosis and acute management J Neurol Neurosurg Psychiatry, 2021.PMID 33649022
  6. [6]Dalmau J, Graus F Antibody-Mediated Encephalitis N Engl J Med, 2018.PMID 29490181