Electroconvulsive Therapy for Catatonia in NMDA Receptor Encephalitis Unresponsive to Immunotherapy in a Five Year Old

Anti-NMDA (N-methyl-D-aspartate) receptor encephalitis (NMDARE) is an autoimmune disease associated with a variety of neuropsychiatric signs and symptoms. Among the most common presentations is catatonia, a psychomotor syndrome associated with mutism, stupor, and abnormal or repetitive movements. Catatonia increases the morbidity associated with NMDARE and must be treated aggressively. Although immunotherapy is the mainstay of treatment for NMDARE, such treatment can take prolonged periods of time to take effect, and thus, alternative approaches to the management of catatonia must be considered. The gold standard treatment for catatonia in psychiatric populations is electroconvulsive therapy (ECT), although there is often hesitance to use this in pediatric populations due to limited evidence, concerns about cognitive impact, and, in some cases, state-level legal restrictions on its use. Here, we report the case of a 5-year-old girl with NMDARE who remained catatonic for 8 months despite treatment with numerous immunotherapeutic agents and high-dose lorazepam and whose catatonia responded robustly and ultimately resolved with the initiation of ECT. This response significantly preceded the introduction of additional immunotherapy, suggesting strongly that ECT had a causal impact. The patient approached premorbid levels of motor and cognitive function within 3 months of the initiation of ECT. This case suggests a benefit of ECT augmentation of immunotherapy as a symptomatic treatment for catatonia in NMDARE.