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Oophorectomy in NMDA receptor encephalitis and negative pelvic imaging
  1. Dustin Anderson1,
  2. Nabeela Nathoo2,
  3. Monica Henry1,
  4. George Wood3,
  5. Penelope Smyth2,
  6. Jennifer McCombe2
  1. 1 Critical Care, University of Alberta, Edmonton, Canada
  2. 2 Medicine (Neurology), University of Alberta, Edmonton, Canada
  3. 3 Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
  1. Correspondence to Jennifer McCombe, 7-132D Clinical Sciences Building, 11350 83 Avenue, Edmonton, T6G 2G3, Canada; jmccombe{at}ualberta.ca

Abstract

Ovarian teratomas are found in one-third of females presenting with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. When a teratoma is detected on imaging, its removal is first-line therapy. Even with multiple imaging modalities, occasionally, the teratoma is found only on subsequent imaging, long after initial presentation. Very rarely, patients have undergone oophorectomy despite negative imaging, with pathology demonstrating teratoma, and resulting clinical improvement. We present a patient in whom removal of a teratoma, not visible on conventional imaging, resulted in marked clinical improvement. Such cases present a major clinical challenge, needing to consider the risks of oophorectomy, including sterilisation and early menopause, versus the possibility of death in the absence of response to first-line (eg, corticosteroids, plasma exchange, intravenous immunoglobulin), second-line (eg, rituximab) and third-line (eg, bortezomib) immunosuppression. This decision is made more difficult as patients are usually females of childbearing age who at the time lack capacity to make medical decisions. This case also highlights the lack of consensus and guidelines for imaging modalities used to detect teratoma and when to pursue oophorectomy.

  • NMDA
  • Intensive care
  • genitourinary medicine
  • paraneoplastic syndrome
  • quality of life
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Footnotes

  • DA and NN contributed equally

  • Contributors DA, NN and JM drafted the original manuscript. All authors were directly involved in the patient’s care and management, provided intellectual content for the manuscript, and edited the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Consent obtained from parent(s)/guardian(s).

  • Ethics approval The patient’s mother provided consent for publication of this case.

  • Provenance and peer review Not commissioned. Externally peer reviewed by Adam Al-Diwani, Oxford, UK.

  • Data availability statement Not applicable.

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  • Editors’ commentary
    Phil E M Smith Geraint N Fuller

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