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Final Program


Final Program

1628 - Multidisciplinary Management of Anti-NMDA Receptor Encephalitis with MOGAD/FLAMES overlap in Acute Inpatient Rehabilitation: A Case Report

Friday, February 28, 2025
5:00 PM - 6:30 PM MST

    Presenting Author(s)

  • TM

    Timothy Mason, MD

    Resident Physician
    NM Marianjoy Rehabilitation Hospital
    Wheaton, Illinois, United States

    • Co-Author(s)

  • SR

    Sparsh Ray, MD

    Resident Physician
    NM Marianjoy Rehabilitation Hospital
    Oak Park, Illinois, United States

  • HK

    Henry Kotlinski, BS

    Medical Student
    Marian University Wood College of Osteopathic Medicine
    indianapolis, Indiana, United States

  • LZ

    Liridon Zendeli, MD

    Physician
    NM Marianjoy Rehabilitation Hospital
    Wheaton, Illinois, United States

Case Diagnosis: Anti-NMDA Receptor Encephalitis with MOGAD/FLAMES Overlap 

Case Description: A 42-year-old woman with a history of hyperlipidemia and pre-diabetes presented with severe headache, neck pain, altered mental status (AMS), and fever, initially suggesting meningoencephalitis. After an infectious work-up and two weeks of antibiotics and antifungals without improvement, MRI showed leptomeningeal enhancement and sulcal FLAIR hyperintensities. Positive anti-NMDA-R antibodies (1:128 titer) and a positive serum MOG antibody (1:100) raised concern for anti-NMDA-R encephalitis with MOGAD/FLAMES overlap. Neurology and Neuroimmunology teams initiated IVIG, high-dose corticosteroids, and plasmapheresis, leading to significant improvement in AMS and agitation. The patient was then transferred to acute inpatient rehabilitation (AIR) for functional recovery. 

Discussions: Anti-NMDA-R encephalitis with MOGAD/FLAMES overlap is a rare condition and the rehabilitation of these patients can be challenging and is underreported. Anti-NMDA-R encephalitis presents with psychiatric symptoms like AMS, agitation, and catatonia, while MOGAD involves atypical manifestations of demyelination such as headache, fever, epilepsy, and aphasia. This patient initially showed MOGAD symptoms, later developing Anti-NMDA-R encephalitis predominant symptoms, including agitation, hallucinations, and seizures. The patient’s AIR course was collaboratively managed by physiatry, psychiatry, and nursing as episodes of acute agitation were frequent. With the addition of non-sedating medications and minimal restraint use, this patient was able to participate in intensive physical, occupation and speech therapy. She progressed from requiring minimal assistance to achieving near independence in activities of daily living (ADLs) and mobility. 

Conclusions:

Studies have shown titer levels of anti-NMDA-R titers in this overlap syndrome are positively correlated with poor prognosis. This patient had a titer level far above the upper limits documented in the literature, and over 10x times the average of those diagnosed. These patients are at high risk for relapse and a protracted recovery course. Collaborative treatment facilitated this patient’s functional and cognitive recovery despite the behavioral challenges associated with these conditions.