The most common type of Autoimmune Encephalitis, anti-NMDA receptor Autoimmune Encephalitis (ANMDARE) which accounts for 20% of cases, was identified in 2005.  Even though The California Encephalitis Project 2007-2011 showed this variant of autoimmune encephalitis occurred more commonly than other etiologies of encephalitis such as enterovirus encephalitis, HSV-1, West Nile Virus or Varicella zoster virus (VZV), many Emergency Department physicians are not familiar with it.  A new specialty, autoimmune neurology, has evolved for clinicians fascinated with this area of medicine. Emergency Departments do evaluate for encephalitis and meningitis but autoimmune encephalitis often goes unrecognized.

Given that Autoimmune Encephalitis is more common than originally thought, Emergency Department Staff, would be well advised to keep autoimmune encephalitis as a differential diagnosis for patients presenting with acute psychosis or encephalitis. This may be particularly important in patients with new onset psychosis being referred to a psychiatric facility, especially if they presented with any neurological symptoms. Psychiatrists and Emergency Room Physicians are often the first to see these patients, data shows that due to the wide spectrum of initial symptoms in AE patients, the correct diagnosis of these patients is often missed or delayed. Therefore, lumbar puncture should be offered to ALL patients with new onset psychosis as part of the broader evaluation for their mental and physical health. 

Autoimmune encephalitis is a treatable disease, and it responds better to early treatment. There are numerous co-hort studies and case reports of patients who demonstrated improvement immediately following immunosuppressant therapy or tumor removal.  Studies have found that favorable outcome is associated with early treatment.  To learn more about Autoimmune encephalitis masquerading as psychosis/psychiatric illness, we highly recommend Psychiatrists, ER physicians and those learning about these disorders review the research under AE -Psychiatric presentation.

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Standard Operating Procedure

This SOP ( From – SOP: antibody-associated autoimmune encephalitis), aims for facilitating the approach to patients with central nervous system symptoms suspicious of AE, for raising awareness of the clinical presentation of such patients, and for proposing the necessary diagnostic and therapeutic steps. 

Click to see the full size table of Most important antibodies and clinical syndromes. 

Neuroimmunology: Updates and antibody test utilization

Mayo Clinic 2021

The primary changes to the autoimmune evaluations include complete removal of striational antibodies and anti-calcium channel antibodies. Although N-type calcium channel antibodies sometimes accompany P/Q-type, and can be associated with cancer, it was determined, overall, that including N-type does not add sufficient value. In addition, P/Q-type antibody will only be used in the Lambert-Eaton syndrome and movement disorders evaluations. Alpha-3 ganglionic acetylcholine receptor antibody will be included in the autonomic dysfunction evaluations only.

These updates are being made on a solid foundation of research.

Recommended Reading for Clinicians

The first medical text for Autoimmune Encephalitis every clinician should have in their library! By Cambridge press and available on Amazon.

Autoimmune encephalitis, diseases where the immune system attacks the brain, have become a fast-moving field of study in recent years. The authors, Drs Josep Dalmau and Francesc Graus, have played pivotal roles in the discovery of these diseases. Here, they provide a comprehensive clinical guide to the differential diagnosis of these disorders, illustrated with over 200 figures, 30 videos and numerous clinical vignettes, many from their own practice. Clinical descriptions are straightforward, emphasizing distinctive diagnostic clues for each disease. The strengths and weaknesses of diagnostic tests and clinical criteria are discussed extensively, as well as the best evidence supporting the use of available treatments. There is an up-to-date description of immunological triggers and comorbidities, and well-illustrated and clearly summarized pathogenic mechanisms and disease models. Gain full HTML access of the whole book, including supplementary videos, via a scratch-off code inside the cover.

This book provides a clinical focus on neuroinflammatory diseases as well as a review in pathophysiology and treatment approaches.

Organized into six parts, the book begins with a basic review of the immune system and concepts for learning and treating neuroimmune conditions. The next four sections cover specific subfields of neuroimmunology and autoimmune neurology – the clinical and diagnostic features of multiple sclerosis, other autoimmune conditions of the central nervous system, autoimmune conditions of the peripheral nervous system, and systemic autoimmune conditions that affect the nervous system. To conclude, Section six discusses various clinical approaches to specific presentations in neuroimmunology, including pediatric demyelinating diseases.  These sections provide practical clinical information to improve the reader’s knowledge in this complex field. The chapters are written by world renown authors with extensive knowledge to help provide up to date information. The full scope of autoimmune neurology is discussed, which is a unique feature of this book.

Neuroimmunology serves as a resource for those in training including residents and fellows to provide clear clinical reasoning and background in a rapidly advancing field.

• Treatable Immune System Disorder Could Be Mistaken For Schizophrenia or Bipolar Disorder
• Autoimmune Encephalitis: Current concepts 2017
• AE Treatment Strategies
• The Laboratory Diagnosis of Autoimmune Encephalitis
• Neural Antibody Testing in Patients with Suspected Autoimmune Encephalitis-2020
• The Diagnosis and Treatment of Autoimmune Encephalitis
• Symptoms associated with antibody-mediated Autoimmune Encephalitis
• Encephalopathy with EEG based grading (slide show)
• Encephalopathic EEG Patterns

• Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients
• Phases of Autoimmune Encephalitis
• Recognizing Autoimmune-Mediated Encephalitis
• Autoimmune Encephalitis: A need for increased awareness among Psychiatrists

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