Topiramate as Possible Treatment for Catatonia in Anti-NMDA Receptor Encephalitis

Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is a disorder characterized by the presence of pathological auto-antibodies, frequently paraneoplastic, and presenting primarily in young women. The condition has a variable neuropsychiatric presentation, with symptoms frequently including agitation, psychotic symptoms, behavioral changes, generalized or partial seizures, autonomic abnormalities, and hypoventilation. Catatonic symptoms are also frequently present. Catatonia is a syndrome of unclear pathophysiology, hypothesized to be caused by an underlying dysfunction in the GABA­ergic system and typically treated with the benzodiazepine lorazepam or electroconvulsive therapy (ECT). However, there is also evidence for the involvement of glutamate in catatonia, as well as the efficacy of glutamatergic agents, including amantadine, memantine, and topiramate. Here, the authors present the case of a 20-year-old female patient who was admitted with a severe catatonia in the setting of anti-NMDA receptor encephalitis. Because of concerns for side effects of lorazepam and ECT, the patient elected to try a different treatment. Topiramate was chosen due to its good tolerability, prior evidence of efficacy in catatonia (though not in cases of anti-NMDA receptor encephalitis), and its mechanism of action on both GABA receptors and on kainate and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptors. The patient improved rapidly with the treatment. To the authors' knowledge, this is the first published case of successful treatment of catatonia in anti-NMDA receptor encephalitis with topiramate.