A 16-year-old high school student began seeing and hearing things that were not real. Her most vivid vision was a flying green dinosaur. She also heard voices telling her to hurt herself and felt that people were following her.
Her parents had seen changes weeks earlier. The teenager’s strong grades had slipped, and she had withdrawn from friends and activities.
When the hallucinations began abruptly, she was taken to hospital. Blood work, brain scans and basic checks returned normal results, and doctors gave medication for psychosis while treating possible psychiatric causes.
The explanation emerged only after nearly three weeks in hospital and many specialist visits. A specialised spinal fluid test found antibodies attacking the heavy-chain neuronal intermediate filament, known as anti-NIF.
Doctors diagnosed autoimmune encephalitis, a condition in which the immune system mistakenly attacks the brain. They began immune-modulating treatment, managed infections that appeared and checked for hidden cancer.
Her hallucinations and other symptoms gradually faded. She left hospital well and remained stable on immunotherapy the following year without psychiatric drugs.
Psychiatric symptoms can emerge early in autoimmune encephalitis before neurological signs appear. Autoimmune neurological disorders can affect thinking, behaviour or alertness, and may lead to confusion, memory problems, personality changes, unusual movements or seizures.
Anti-NMDA receptor encephalitis is the most common form in the pediatric age group, up to 18 years, representing 40% of cases. It is more prevalent in females, and its psychiatric manifestations can include agitation, anxiety, bizarre behaviour, hallucinations, delusions and disorganised thoughts.
Many patients with anti-NMDA receptor encephalitis are first seen by psychiatry before neurological progression clarifies the diagnosis. Early assessment by a neurologist, and often a neuroimmunology specialist, can help establish the cause.
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