A 42-year-old female presented with new auditory and visual hallucinations and headaches. Per collateral, she was found speaking to pictures on the walls. In the ED, she exhibited delusions, hallucinations, paranoia, pressured speech, and tangential thinking. On examination, she was oriented to self only, intact cranial nerves, strength, sensation to light touch and reflexes.
CT Head revealed a hypodense, calcified lesion in the left temporal lobe and insula with surrounding vasogenic edema. MRI Brain demonstrated a contrast enhancing lesion in the left temporal lobe and insula with significant vasogenic edema. Video EEG was notable for left temporal focal slowing without evidence of seizures or epileptiform discharges. MRI spectroscopy was notable for concerns of a primary high grade glial neoplasm given increased choline peak, decreased N-acetyl aspartate (NAA) peak and an elevated lactate peak. Preliminary cerebrospinal fluid results included total cells 32 (29 lymphocytes and 3 monocytes), protein 30, and glucose 55. Given high concern that the temporal lobe lesion was a glioma, the patient was discharged with outpatient neurosurgery follow-up.
The patient tested positive for CSF anti-NMDA receptor three weeks later, prompting re-hospitalization for further treatment. The patient completed three days of intravenous (IV) methylprednisolone 1 g daily, five days of IVIG 0.4 g/kg, and five sessions of plasmapheresis alternating with IV methylprednisolone 500 mg daily on non-plasmapheresis days with radiographic and clinical improvement.