SHM Converge Scientific Abstract ePoster Gallery-Misterious Encephalopathy: A Diagnostic Dilemma

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The poster presents a challenging case of encephalopathy using the MIST framework: metabolic, infectious, structural, and toxic causes. The patient was a 58-year-old woman with a history of hypertension and rheumatoid arthritis who developed 4 days of worsening altered mental status, weakness, and anorexia. Six months earlier, she had been hospitalized for severe COVID-19 requiring intubation and was treated at an outside hospital for presumed autoimmune encephalopathy with steroids and plasmapheresis, after which she returned to her baseline mental and functional status. She had no symptom recurrence in the interim.<br /><br />Given her presentation and history, the active differential included autoimmune encephalitis, including anti-NMDA receptor encephalitis potentially associated with COVID infection and multiple myeloma; hyperammonemic encephalopathy, which is rare but can occur in advanced treatment-resistant multiple myeloma; paraneoplastic syndrome; acute disseminated encephalomyelitis (ADEM); and hyperviscosity. The authors note that a negative autoimmune panel does not exclude autoimmune encephalitis. They also suggest that both ADEM and paraneoplastic syndromes could be related to transient blood-brain barrier disruption during her prior COVID infection.<br /><br />At 1-year follow-up, the patient had been treated for multiple myeloma with Dara-RVd and was planned for autologous stem cell transplant, with no recurrence of symptoms to date. The case highlights the importance of a broad differential for encephalopathy and the potential neurologic complications associated with COVID-19 and multiple myeloma.

Asset Subtitle

Jonathan Hickman

Meta Tag

Author List Amber Feinman, Ashley M. Otto, Jonathan Hickman

Category Clinical Vignettes

Concept MIST mnemonic

Concept Encephalopathy

Concept Autoimmune Encephalitis

Concept Hyperammonemia

Concept Delirium

Distinguished Non-Finalist

Presenter Organization Naval Medical Center Portsmouth

Presenting Author Jonathan Hickman

Track Adult

Keywords

encephalopathy

multiple myeloma

autoimmune encephalitis

COVID-19

anti-NMDA receptor

hyperammonemia

paraneoplastic syndrome

ADEM

altered mental status

blood-brain barrier

MIST mnemonic

Encephalopathy

Autoimmune Encephalitis

Hyperammonemia

Delirium