The current guidelines recommend screening all patients with first episode psychosis (FEP) for anti-NMDA receptor encephalitis. This paper explores the pitfalls of this strategy.
Conclusion:
Screening for anti-NMDA receptor encephalitis in patients with FEP when the pre-test probability based on the clinical presentation is low creates a risk of false positive results. Testing based on clinical suspicion would be preferable.
DalmauJLancasterEMartinez-HernandezE, et al. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol2011; 10: 63–74.
2.
GalletlyCCastleDDarkF, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry2016; 50: 410–472.
3.
ScottJGillisDRyanA, et al. The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis. B J Psych2018; 4: 69–74.
4.
DalmauJTuzunEWuH, et al. Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol2007; 61: 25–36.
5.
VenkatesanA.Immune-mediated encephalitis for the infection diseases specialist. Curr Opin Infect Dis2019; 32: 251–258.
6.
MuellerSFarberAPrussH, et al. Genetic predisposition in anti-LGI1 and anti-NMDA receptor encephalitis, Ann Neurol2018; 83: 863–869.
7.
KayserMDalmauJ.Anti-NMDA receptor encephalitis in psychiatry. Curr Psychiatry Rev2011; 7: 189–193.
8.
WhitingPDavenportCJamesonC, et al. How well do health professionals interpret diagnostic information? A systematic review. Diagnostics Research2015; 5: 1–8.
9.
YoungJGlasziouPWardJ.General practitioners’ self ratings of skills in evidence based medicine: validation study. BMJ2002; 324: 950–951.
10.
SoxHSternSOwensD, et al. Assessment of diagnostic technology in health care: rationale, methods, problems and directions: monograph of the council on eHealth care technology. Institute of Medicine (US), Council on Health Care Technology. Washington (DC): National Academies Press (US), 1989.
11.
SackettDHynesRGuyattG, et al. Clinical epidemiology: a basic science for clinical medicine. 2nd edn.Boston, MA: Little, Brown, 1991.
12.
KelleherEMcNamaraPFitzmauriceB, et al. Prevalence of N-methyl-d-aspartate (NMDA) Receptor Antibodies in First Episode Psychosis. Eur Psychiatry2015; 30: 28–31.
13.
CardinalL.Diagnostic testing in the context of high-value care: incorporating prior probability. J Community Hosp Intern Med Perspect2016; 6: 33674.
14.
LennoxBPalmer-CooperEPollakT, et al. Prevalence and characteristics of serum neuronal cell surface antibodies in first-episode psychosis: a case-control study. Lancet Psychiatry2017, 4: 42–48.
15.
ZandiMPatersonREllulM, et al. Clinical relevance of serum antibodies to extracellular N-methyl-d-aspartate receptor epitopes. J Neurol Neurosurg Psychiatry2015; 86: 708–713.
16.
Gresa-ArribasNMaartenTTorrentsA, et al. Diagnosis and significant of antibody titers in anti-NMDA receptor encephalitis, a retrospective study. Lancet Neurol2014; 12: 167–177.
17.
McCrackenLZhangJGreeneM, et al. Improving the antibody-based evaluation of autoimmune encephalitis. Neurol Neuroimmunol Neuroinflamm2017; 4(6): e404.
18.
ZhangTDuanYYeJ, et al. Brain MRI characteristics of patients with Anti-N-Methyl-D-Aspartate receptor encephalitis and their associations with 2-year clinical outcome. Am J Neuroradiol2018; 39: 824–829.
19.
ScottJGillisDSwayneA, et al. Testing for antibodies to N-methyl-d-aspartate receptor and other neuronal cell surface antigens in patients with early psychosis. Aust N Z J Psychiatry2018; 52: 727–729.
20.
GrausFTitulaerMBaluR, et al. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol2016; 15: 301–304.
21.
PollackTLennoxBMullerS, et al. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry2020; 7(1): 93–108.
22.
TongJHuangJLuoX, et al. Elevated serum anti-NMDA receptor antibody levels in first-episode patients with schizophrenia. Brain Behav Immun2019; 81: 213–219.
23.
DalmauJArmanqueTPlanaqumaJ, et al. An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol2019; 19: 30244–30243.
