Demonic Possession or Something else… Anti-NMDAR Encephalitis: A Case Report

Acute confusional state is a challenging condition especially when present in young patients. I am presenting a challenging case of acute confusion in a young patient which was not diagnosed in a timely manner. A 33-year-old pleasant lady was initially admitted with fits and managed with sodium valproate. There were no past medical problems. No cause was found and she was discharged with outpatient neurologist follow up. One week later she re-admitted with confusion, bizarre behaviour and personality change. Her confusion got worse and her personality was changed to that extent that her family and other ward members including nursing staff felt about demonic possession. This presentation was considered secondary to sodium valproate which was changed to phenytoin. Afterward, she went through extensive investigations including CT head, MRI head and Spine, Lumbar puncture, Septic & autoimmune screen. Her pregnancy test was negative. LP results confirmed leucocytosis and EEG showed diffuse abnormality. MRI head showed encephalitis changes, MRV was normal. CSF culture did not grow any organism. She was treated with 14 days course of IV Aciclovir for? encephalitis which did not help and her condition deteriorated further and she was transferred to ITU. Neurologist subsequent review advised for VGKC, NMDA, GAD & Paraneoplastic antibodies. NMDA receptor antibodies result later came back positive. She had a CT TAP & TV ultrasound which ruled out any ovarian malignancy. She was treated with immunoglobins & IV steroids & her condition improved slightly however later she aspirated during fitting and was intubated and transferred to tertiary hospital where she received plasma exchange and got almost full recovery.