New-onset seizures misdiagnosed as psychogenic non-epileptic seizures: a case of paraneoplastic limbic encephalitis with primary testicular cancer

Axel Rivas, Daniel Levine, Cory Nichols, Mckenzie Merritt, Paul Janda, Aroucha Vickers
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引用次数: 0

Abstract

Behavioral psychiatric symptoms can be the only warning signs of more serious conditions such as paraneoplastic limbic encephalitis. Differentiating between primary psychiatric disorders and paraneoplastic neurological syndromes is crucial as they require distinct treatment approaches. In this case report, we provide an overview of paraneoplastic encephalitis and introduce a unique case that showcases a misdiagnosis of psychogenic non-epileptic seizures (PNES) in a male as the primary symptom of paraneoplastic encephalitis due to pure seminoma. This case highlights the underlying pathophysiology of antibody-mediated paraneoplastic encephalitis and its significance. A 31-year-old male with no known past medical history presented due to recurrent seizures. There was no prior history of epilepsy or exposure to seizure-triggering agents. Imaging and electroencephalogram findings during his initial hospitalizations pointed to a potential diagnosis of PNES. The patient continued to experience seizures following discharge, leading to repeat hospitalizations. During the fourth hospitalization, the patient received mood-stabilizing anti-seizure medications and benzodiazepines, but he deteriorated and required intubation. It was during this time that the patient was transferred to our facility. Magnetic resonance imaging of the brain revealed multifocal areas of hyperintensity and restricted diffusion with avid enhancement. Immunotherapy was initiated with improvement of non-epileptic spells and encephalopathy. Outpatient workup uncovered malignant pure seminoma with metastases to the retroperitoneum. The authors theorize that paraneoplastic neurological disorders stemming from testicular cancer led to the neurological symptoms seen in this case. This report highlights a rare occurrence of paraneoplastic limbic encephalitis associated with pure testicular seminoma, clinically manifested as PNES. The diagnostic challenge posed by variability of presenting symptoms in paraneoplastic encephalitis emphasizes the importance of accurate differentiation from conditions such as autoimmune encephalitis. Current diagnostic approaches for paraneoplastic and autoimmune etiologies involve detection of known antibodies, as well as brain imaging. Notable antibodies associated with psychogenic non-epileptic seizures symptoms include anti-GAD-65, anti-Ma2, KLH11-antibodies, anti-Hu, and NMDA receptor antibodies. Recognizing paraneoplastic limbic encephalitis symptoms is challenging and often leads to misdiagnosis or overlooking of malignancies highlighting the need for awareness, comprehensive evaluation and timely treatment. Through this comprehensive case analysis, we enhance the understanding of underlying mechanisms, associated symptoms, and treatment options.
被误诊为精神性非癫痫发作的新发癫痫发作:一例原发性睾丸癌并发副肿瘤性肢端脑炎的病例
行为性精神症状可能是副肿瘤性肢端脑炎等更严重疾病的唯一预警信号。区分原发性精神障碍和副肿瘤性神经综合征至关重要,因为它们需要不同的治疗方法。在本病例报告中,我们概述了副肿瘤性脑炎,并介绍了一例独特的病例,该病例将一名男性的精神性非癫痫性发作(PNES)误诊为纯精原细胞瘤所致副肿瘤性脑炎的主要症状。该病例强调了抗体介导的副肿瘤性脑炎的基本病理生理学及其重要性。一名 31 岁的男性因癫痫反复发作就诊,既往无病史。既往无癫痫病史,也未接触过诱发癫痫发作的药物。最初住院期间的影像学和脑电图检查结果表明他可能被诊断为 PNES。患者出院后癫痫继续发作,导致再次住院。第四次住院期间,患者接受了稳定情绪的抗癫痫药物和苯二氮卓类药物治疗,但病情恶化,需要插管。就在这期间,病人被转到了我们医院。脑部磁共振成像显示多灶性高密度区和弥散受限区,并伴有血管强化。患者开始接受免疫治疗,非癫痫性痉挛和脑病有所改善。门诊检查发现了恶性纯精索瘤,并向腹膜后转移。作者推断,睾丸癌引起的副肿瘤性神经紊乱导致了本病例中出现的神经症状。本报告强调了与纯睾丸精原细胞瘤相关的副肿瘤性肢端脑炎的罕见病例,临床表现为 PNES。副肿瘤性脑炎表现症状的多变性给诊断带来了挑战,强调了与自身免疫性脑炎等疾病准确鉴别的重要性。目前对副肿瘤性和自身免疫性病因的诊断方法包括检测已知抗体和脑成像。与精神性非癫痫发作症状相关的抗体包括抗-GAD-65、抗-Ma2、KLH11-抗体、抗-Hu和NMDA受体抗体。识别副肿瘤性肢端脑炎症状具有挑战性,往往会导致误诊或忽略恶性肿瘤,因此需要提高认识、全面评估和及时治疗。通过这篇全面的病例分析,我们加深了对潜在机制、相关症状和治疗方案的理解。
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