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Neuropsychiatric decline and status epilepticus in pregnancy
  1. Ameeta Karmarkar1,
  2. Jeffrey Gelfand2,
  3. Nichole Tackett3,
  4. Emily Black4,
  5. Rowena Desailly-Chanson1,
  6. Ryan Lapointe5
  1. 1MGC Inpatient Medicine, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
  2. 2Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco (UCSF), San Francisco, California, USA
  3. 3PGY-1 General Surgery, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
  4. 4Greenwood Genetic Center, Greenville, South Carolina, USA
  5. 5Critical Care Medicine, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
  1. Correspondence to Dr Ameeta Karmarkar, Neurohospitalist, MGC Inpatient Medicine, 101 E Wood St, Spartanburg Regional Healthcare System, Spartanburg SC 29303, South Carolina, USA; akarmarkar{at}srhs.com

https://doi.org/10.1136/pn-2024-004283

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    Case presentation

    A 25-year-old left-handed woman (G2P1) was hospitalised at 29 weeks gestation for progressive cognitive decline, mood change, gait instability and weight loss.

    Her symptoms had begun at 16 weeks gestation with anhedonia, insomnia and a loss of interest in daily activities. She became socially withdrawn, apathetic and minimally conversant with family members. She reported nausea and anorexia, resulting in poor oral intake and an unintentional weight loss of 11 pounds over 2 months. She developed a labile affect, with a depressed mood alternating with rambling, pressured speech and flight of ideas. Over the next 4 weeks, she developed progressive word-finding difficulty, confusion, bilateral leg weakness and urinary incontinence, leading to hospitalisation.

    Her family had immigrated to the USA when she was a toddler. Her developmental history had been normal. When she was 12 weeks into her first pregnancy 2 years before, she had developed bizarre behaviour and personality changes, with frequent verbal altercations, concentration difficulty, panic attacks, emotional lability and insomnia. She received psychotherapy but did not need medication or hospitalisation. The symptoms resolved spontaneously after the third trimester, and she returned to her previous level of functioning.

    There was no relevant family history. She did not smoke, drink alcohol or use illegal substances.

    On examination, she was underweight, alert and inattentive, with normal vital signs. She had a flat affect, was minimally verbal and was orientated only towards herself. Eye movements showed hypometric saccades on left gaze, proximal bilateral lower limb weakness (4/5 hip flexion and extension), 3+ deep tendon reflexes and extensor plantar responses. Cognitive performance was severely impaired, scoring only 5/30 on the St Louis Mental Status Examination (SLUMS).

    What is the most likely diagnosis?

    What is the most appropriate initial management?

    In a pregnant woman with anorexia, our initial concern was nutritional deficiency. A full blood count found mild leucopenia with a white blood cell count of 2.9×109 …

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    Footnotes

    • Contributors AK is the guarantor. AK worked on acquiring patient consent, performed compilation and analysis of patient data, drafted and revised the main document, prepared figures and tables and was involved in final approval and manuscript submission. JMG made substantial contributions by reviewing the case presentation and making important additions in the discussion section pertaining to neuroinflammatory disease, made essential edits and revisions to the draft, provided valuable intellectual input and was involved in the final approval. NT made major contributions to the acquisition and compilation of patient’s laboratory test results and preparation of case presentation. NT made revisions to the draft and was involved in the final approval. EB made important contributions to the discussion of metabolic disorders, especially pertaining to pregnancy and was involved in drafting and revising the main document and in final approval. RDC made contributions to the case presentation by compiling and documenting the hospital course and laboratory investigations and was involved in drafting and revising the main document and in final approval. RL made contributions to the case presentation, particularly the intensive care course, by compiling and documenting the details of hospitalisation and laboratory investigations and was involved in drafting and revising the main document and in final approval. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • 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 JMG: Research support from Hoffman LaRoche and Vigil Neurosciences for clinical trials and consulting for Arialys and Ventyx Bio.

    • Provenance and peer review Not commissioned. Externally peer reviewed by Lina Nashef, London, UK.