{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T17:47:28Z","timestamp":1763142448205,"version":"3.44.0"},"reference-count":41,"publisher":"BMJ","issue":"5","license":[{"start":{"date-parts":[[2025,5,9]],"date-time":"2025-05-09T00:00:00Z","timestamp":1746748800000},"content-version":"unspecified","delay-in-days":8,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,4,21]]},"published-print":{"date-parts":[[2025,5]]},"abstract":"<jats:p>Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a rare subtype of autoimmune encephalitis, often presenting with early-onset, disease-specific neuropsychiatric symptoms. This case report describes a female patient with relapsing-remitting multiple sclerosis (RRMS) who developed anti-NMDA receptor encephalitis while receiving disease-modifying treatment. She exhibited neurocognitive symptoms and atypical magnetic resonance findings. Clinical and laboratory findings, including lumbar puncture, confirmed the presence of IgG antibodies against the GluN1 subunit of the NMDA receptor, establishing the diagnosis. First-line therapy with methylprednisolone and plasma exchange proved refractory, and immunoglobulin therapy yielded only a suboptimal response. Rituximab achieved the optimal therapeutic effect; however, therapy was followed by recurrent COVID-19 infection in this previously unvaccinated patient. This report highlights the complexities of diagnosis, differential considerations, therapeutic strategies and the detrimental impact of anti-NMDA receptor encephalitis and RRMS on the patient\u2019s quality of life.<\/jats:p>","DOI":"10.1136\/bcr-2024-263945","type":"journal-article","created":{"date-parts":[[2025,5,9]],"date-time":"2025-05-09T00:30:18Z","timestamp":1746750618000},"page":"e263945","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Development of anti-NMDA receptor encephalitis in a patient with multiple sclerosis"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0666-839X","authenticated-orcid":false,"given":"El\u012bna","family":"Polunosika","sequence":"first","affiliation":[{"name":"Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8056-7087","authenticated-orcid":false,"given":"Daina","family":"Pastare","sequence":"additional","affiliation":[{"name":"Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9586-2775","authenticated-orcid":false,"given":"Guntis","family":"Karelis","sequence":"additional","affiliation":[{"name":"Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vladyslava","family":"Vasylovska","sequence":"additional","affiliation":[{"name":"Uppsala Universitet, Uppsala, Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,5,8]]},"reference":[{"key":"2025082804142522000_18.5.e263945.1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1708712"},{"key":"2025082804142522000_18.5.e263945.2","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(19)30244-3"},{"key":"2025082804142522000_18.5.e263945.3","doi-asserted-by":"crossref","DOI":"10.1136\/bcr-2017-222086","article-title":"NMDAR (N-methyl-D-aspartate receptor) encephalitis in a patient with MS (multiple sclerosis): a rare and challenging case","volume":"2018","author":"Suleman","year":"2018","journal-title":"BMJ Case Rep"},{"key":"2025082804142522000_18.5.e263945.4","doi-asserted-by":"crossref","first-page":"102075","DOI":"10.1016\/j.msard.2020.102075","article-title":"Co-existence of multiple sclerosis and anti-NMDA receptor encephalitis: A case report and review of literature","volume":"42","author":"Gulec","year":"2020","journal-title":"Mult Scler Relat Disord"},{"key":"2025082804142522000_18.5.e263945.5","doi-asserted-by":"crossref","DOI":"10.1186\/s12888-021-03351-7","article-title":"Anti-N-methyl-D-aspartate receptor encephalitis presenting as atypical psychosis in multiple sclerosis: a case report","volume":"21","author":"Chahal","year":"2021","journal-title":"BMC Psychiatry"},{"key":"2025082804142522000_18.5.e263945.6","doi-asserted-by":"crossref","DOI":"10.1093\/braincomms\/fcac196","article-title":"Cytokine dynamics and targeted immunotherapies in autoimmune encephalitis","volume":"4","author":"Ciano-Petersen","year":"2022","journal-title":"Brain Commun"},{"key":"2025082804142522000_18.5.e263945.7","first-page":"109","article-title":"Progressive Multifocal Leukoencephalopathy: Current Insights","volume":"9","author":"Kartau","year":"2019","journal-title":"Degener Neurol Neuromuscul Dis"},{"key":"2025082804142522000_18.5.e263945.8","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1016\/j.clinimag.2017.08.008","article-title":"The imaging spectrum of posterior reversible encephalopathy syndrome: A pictorial review","volume":"47","author":"Brady","year":"2018","journal-title":"Clin Imaging"},{"key":"2025082804142522000_18.5.e263945.9","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199602223340803"},{"key":"2025082804142522000_18.5.e263945.10","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp.2007.124263"},{"key":"2025082804142522000_18.5.e263945.11","unstructured":"Green K , Munakomi S , Hogg JP . Central nervous system lymphoma. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2024. Available: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK545145"},{"key":"2025082804142522000_18.5.e263945.12","doi-asserted-by":"crossref","first-page":"1756286418793562","DOI":"10.1177\/1756286418793562","article-title":"Primary central nervous system lymphoma","volume":"11","author":"L\u00f6w","year":"2018","journal-title":"Ther Adv Neurol Disord"},{"key":"2025082804142522000_18.5.e263945.13","doi-asserted-by":"crossref","first-page":"66","DOI":"10.29271\/jcpsp.2018.01.66","article-title":"Primary CNS Lymphoma vs. Tumefactive Multiple Sclerosis: A Diagnostic Challenge","volume":"28","author":"Naeem","year":"2018","journal-title":"J Coll Physicians Surg Pak"},{"key":"2025082804142522000_18.5.e263945.14","doi-asserted-by":"publisher","DOI":"10.3174\/ajnr.A2171"},{"key":"2025082804142522000_18.5.e263945.15","doi-asserted-by":"crossref","DOI":"10.1186\/s12883-022-02821-z","article-title":"Primary large B-cell lymphoma of the central nervous system with positive NMDAR antibody: a case report","volume":"22","author":"Li","year":"2022","journal-title":"BMC Neurol"},{"key":"2025082804142522000_18.5.e263945.16","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1186\/s43055-023-01066-1","article-title":"MRI features of myelin oligodendrocyte glycoprotein antibody disease: a descriptive study\u2014how it differs from neuromyelitis optica spectrum disorders and multiple sclerosis","volume":"54","author":"Tom Mishael","year":"2023","journal-title":"Egypt J Radiol Nucl Med"},{"key":"2025082804142522000_18.5.e263945.17","doi-asserted-by":"publisher","DOI":"10.1002\/ana.26931"},{"key":"2025082804142522000_18.5.e263945.18","doi-asserted-by":"publisher","DOI":"10.3174\/ajnr.A5593"},{"key":"2025082804142522000_18.5.e263945.19","doi-asserted-by":"crossref","first-page":"ii68","DOI":"10.1093\/rheumatology\/kew353","article-title":"The gut\u2013brain connection: triggering of brain autoimmune disease by commensal gut bacteria","volume":"55","author":"Wekerle","year":"2016","journal-title":"Rheumatology (Sunnyvale)"},{"key":"2025082804142522000_18.5.e263945.20","doi-asserted-by":"publisher","DOI":"10.1002\/ana.24117"},{"key":"2025082804142522000_18.5.e263945.21","doi-asserted-by":"crossref","first-page":"857443","DOI":"10.3389\/fimmu.2022.857443","article-title":"Clinical Characteristics of Anti-N-Methyl-d-Aspartate Receptor Encephalitis Overlapping with Demyelinating Diseases: A Review","volume":"13","author":"Zhang","year":"2022","journal-title":"Front Immunol"},{"key":"2025082804142522000_18.5.e263945.22","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1001\/jamaneurol.2014.1817","article-title":"Severe cognitive impairment associated with intrathecal antibodies to the NR1 subunit of the N-methyl-D-aspartate receptor in a patient with multiple sclerosis","volume":"72","author":"Fleischmann","year":"2015","journal-title":"JAMA Neurol"},{"key":"2025082804142522000_18.5.e263945.23","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(13)70282-5"},{"key":"2025082804142522000_18.5.e263945.24","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-023-38462-6","article-title":"The relevance of NMDA receptor antibody-specific index for diagnosis and prognosis in patients with anti-NMDA receptor encephalitis","volume":"13","author":"H\u00fcmmert","year":"2023","journal-title":"Sci Rep"},{"key":"2025082804142522000_18.5.e263945.25","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(10)70253-2"},{"key":"2025082804142522000_18.5.e263945.26","first-page":"e1386","article-title":"Clinical and pathogenic significance of IgG, IgA, and IgM antibodies against the NMDA receptor","volume":"90","author":"Hara","year":"2018","journal-title":"Neurology (ECronicon)"},{"key":"2025082804142522000_18.5.e263945.27","doi-asserted-by":"crossref","first-page":"1489","DOI":"10.1038\/s41380-017-0011-3","article-title":"Uncoupling the widespread occurrence of anti-NMDAR1 autoantibodies from neuropsychiatric disease in a novel autoimmune model","volume":"24","author":"Pan","year":"2019","journal-title":"Mol Psychiatry"},{"key":"2025082804142522000_18.5.e263945.28","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp-2014-308736"},{"key":"2025082804142522000_18.5.e263945.29","doi-asserted-by":"crossref","DOI":"10.1136\/lupus-2019-000359","article-title":"Differential expression of antibodies to NMDA receptor in anti-NMDA receptor encephalitis and in neuropsychiatric systemic lupus erythematosus","volume":"6","author":"Hirohata","year":"2019","journal-title":"Lupus Sci Med"},{"key":"2025082804142522000_18.5.e263945.30","doi-asserted-by":"crossref","DOI":"10.3389\/fimmu.2021.691536","article-title":"Limitations of a Commercial Assay as Diagnostic Test of Autoimmune Encephalitis","volume":"12","author":"Ruiz-Garc\u00eda","year":"2021","journal-title":"Front Immunol"},{"key":"2025082804142522000_18.5.e263945.31","doi-asserted-by":"publisher","DOI":"10.1016\/j.bbadis.2010.06.017"},{"key":"2025082804142522000_18.5.e263945.32","doi-asserted-by":"publisher","DOI":"10.1038\/mp.2013.110"},{"key":"2025082804142522000_18.5.e263945.33","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(15)00401-9"},{"key":"2025082804142522000_18.5.e263945.34","doi-asserted-by":"crossref","DOI":"10.3389\/fcell.2020.00073","article-title":"Understanding Inflammatory Responses in the Manifestation of Prothrombotic Phenotypes","volume":"8","author":"Chanchal","year":"2020","journal-title":"Front Cell Dev Biol"},{"key":"2025082804142522000_18.5.e263945.35","doi-asserted-by":"crossref","first-page":"3213","DOI":"10.1161\/STROKEAHA.119.026100","article-title":"Serum Anti-NMDA (N-Methyl-D-Aspartate)-Receptor Antibodies and Long-Term Clinical Outcome After Stroke (PROSCIS-B)","volume":"50","author":"Sperber","year":"2019","journal-title":"Stroke"},{"key":"2025082804142522000_18.5.e263945.36","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1159\/000507779","article-title":"Multifocal Stroke Complicating Anti-NMDA Receptor Encephalitis","volume":"12","author":"Stavitsky","year":"2020","journal-title":"Case Rep Neurol"},{"key":"2025082804142522000_18.5.e263945.37","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.114.008323"},{"key":"2025082804142522000_18.5.e263945.38","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1212\/WNL.56.5.628","article-title":"MRI hyperintensities of the temporal lobe and external capsule in patients with CADASIL","volume":"56","author":"O\u2019Sullivan","year":"2001","journal-title":"Neurology (ECronicon)"},{"key":"2025082804142522000_18.5.e263945.39","doi-asserted-by":"crossref","first-page":"1066","DOI":"10.1212\/WNL.57.6.1066","article-title":"Cerebral microbleeds in CADASIL","volume":"57","author":"Lesnik Oberstein","year":"2001","journal-title":"Neurology (ECronicon)"},{"key":"2025082804142522000_18.5.e263945.40","doi-asserted-by":"publisher","DOI":"10.1148\/radiol.2293021354"},{"key":"2025082804142522000_18.5.e263945.41","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1212\/WNL.0b013e3182a4a49c","article-title":"Late-onset anti-NMDA receptor encephalitis","volume":"81","author":"Titulaer","year":"2013","journal-title":"Neurology (ECronicon)"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2024-263945","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T11:14:37Z","timestamp":1756379677000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2024-263945"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5]]},"references-count":41,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,5,8]]},"published-print":{"date-parts":[[2025,5]]}},"alternative-id":["10.1136\/bcr-2024-263945"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2024-263945","relation":{},"ISSN":["1757-790X"],"issn-type":[{"type":"electronic","value":"1757-790X"}],"subject":[],"published":{"date-parts":[[2025,5]]}}}