Grace F. Suttle, MD
Brain Injury Fellow
Rutgers Health/Kessler Insitute for Rehabilitatin
Newark, New Jersey, United States
James W. Guider, MD
Resident
Rutgers Health/Kessler Institute for Rehabilitation
Morristown, New Jersey, United States
Max Zasuly, n/a
Medical Student Researcher
Western University of Health Sciences/Casa Colina Hospital and Centers for Healthcare
Santa Monica, California, United States
Gerardo Rivera-Colón, BS (he/him/his)
Medical Student
Rowan-Virtua School of Osteopathic Medicine
Jackson, New Jersey, United States
Neil Jasey, MD
Attending Physican
Kessler Institute for Rehabilitation
West Orange, New Jersey, United States
HIV Dementia, NMDA Encephalitis
Case Description:
A 17-year-old male with a history of depression presented to the emergency department after multiple falls. He underwent CTH and was found to have obstructive hydrocephalus with ventriculomegaly and underwent a ventriculostomy. The patient continued to experience falls and neurological decline with poor performance in scholarly activities. He was readmitted to the hospital and underwent extensive workup and was found to have elevated HIV viral load and anti-NMDAR antibodies. He was started on antiretroviral therapy and completed a course of Intravenous immunoglobulin (IVIG). He was then discharged to acute inpatient rehabilitation for further care along with pharmacological management addressing symptoms of pseudobulbar affect, hypersexuality, and agitation.
Discussions:
NMDA encephalitis is a rare auto-immune condition marked by a constellation of symptoms, including disturbances of cognition, behaviors, and motor coordination. HIV associated neurocognitive disorders (HAND) are a spectrum of neurocognitive impairments graded by neuropsychological testing and degree of impact on activities of daily living. HAND may occur despite antiretroviral treatment. Our case demonstrates the complexity of multiple disease processes impacting neurocognitive function. During the patient’s rehabilitation stay, he demonstrated symptoms of severe emotional lability and was started on Dextromethorphan/Quinidine. He was started on Escitalopram 10 mg shortly after admission, which was increased to 20 mg daily to target disinhibition and hypersexual symptoms. He continued to have behavioral outbursts, and agitation and was trialed on multiple atypical antipsychotics. Agent selection was limited by drug-to-drug interactions with Dextromethorphan/Quinidine and was ultimately treated with Ziprasidone 40 mg twice daily.
Conclusions:
Physiatrists should be aware of symptoms associated with NMDA encephalitis and HAND. Moreover, there is limited literature on pharmacotherapy to target neurocognitive dysfunction in this patient population. To the best of our knowledge, this is the first case reviewing pharmacotherapy used to manage behaviors associated with HAND in a younger patient.
