Let's Get down to business! To defeat, the autoimmune encephalitides!
Autoimmune Encephalitis is the next topic I will cover.
As much as I want to skip it because its by a UCSF presenter, I'm sure they are not all scourges and shills like Vinay Prasad MD, Monica Gandhi MD (who are in part funded from Enron billionaire money from John Arnold, whom Forbes has referred to as "a disgraced former executive of Enron.")
Richard Jin MD/PhD presenting along with a pediatrician at NIMH, Dr. GenaLynne Mooneyham MD
His primary thesis is neural-immune interactions that may influence neurodevelopment & psychiatric disorders, so more in the lifespan but who knows, possibly some relevance to #LongCOVID, #COVID19, and post-viral neural disorders such as #MultipleSclerosis
Clinical Case: 34yo De-identified Female patient w/ history of PTSD/Depression is admitted for worsening depression and undergoes ECT.
Reports worsening migraines, insomnia. History of depression and suicidal thoughts but the degree of depression has rapidly intensified.
Presents 1 month after ECT with COVID+ test to an outside hospital, confused, possibly delirious, but the hospital attributed this to ECT rather than COVID or immune-brain effects.
Confusion did not happen ever after ECT, but more sudden onset with the positive COVID test result; and now patient developed a fever and worsening confusion so went to another hospital a couple days later cuz first one blew her off.
Neurology was consulted and a lumbar puncture was down: showed leukocytosis and so was started on acyclovir in case of HSV encephalitis. Treated inpatient. Discharged several days later after improved mental status.
Several days after discharge for HSV encephalitis treatment (?Reactivated by COVID? Innocent bystander? COVID also playing a role along with something else?), she develops:
+Sudden onset of generalized seizures twice in a day, with Auditory hallucinations of cats and dogs, and worsened confusion.
These symptoms arent completely uncommon in HSV encephalitis, but a second lumbar puncture was done. CSF PCR was positive for E.Coli.
Presuming infectious causes, an anti-seizure med was started and they shotgun debugged: started both the antiviral acyclovir and the antibiotic ceftriaxone in case of HSV or E. Coli.
Did not really improve but was discharge. Would "wake up with the mental capacity of a toddler" but had new behavioral symptoms: impulsively irritable, poor balance, right-sided weakness
The above is the pathophysiology of autoimmune encephalitis which highlights the role infections play in triggering a bigger problem for the host: attack of their own antigens.
The diagnosis of Autoimmune Encephalitis is generally inductive and should rule out other causes BUT, more specific criteria have been proposed known as the Graus Criteria
Of note, an antibody NEEDNT be identified. That's like looking for a needle in a stack of needles
*Infectious concurrence or precursor
*Paraneoplastic / cancer related
IVIG, IV solumedrol are often initiated in such cases and I believe I've seen cases of success with plasmapheresis as well to treat Autoimmune Encephalitis.
Rituximab or other monoclonal biologics intended to impede the immune system from attacking the brain may be employed as well.
Dr. Mooneyham is taking over and covering the overarching topic of Immunopsychiatry: the interplay of the brain, immune system, and mixed neurologic-psychiatric symptom presentation.
Cool.
The idea of a first hit -- infection -- leading to a second hit -- immune cascade response attacking the body -- is prevalent and possibly pertinent to #COVID19 brain injury and/or to some extent #LongCOVID.
Part 1 for Dr. Mooneyham: Refresher of innate and adaptive immune responses. This is what I will focus on rather than parts 2&3, as they are more specific to consults-liaisons psychiatrists than a general population;
The term "Illness Behaviors" is a landmine chock full of opportunity to be prejudicial against patients or say they are malingering / hysterical / "converting,"
Originally its intent in Neuropsychiatry was to HIGHLIGHT the immune systems effect on behavior.
Interferons, Immunoglobulins, cytokines, etc. do cause behavioral change.
We've known this for a long time -- since Interferon was a treatment option in AIDS.
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