Plasma exchange vs IVIG —> PE Although no systematic comparisons of the three first-line immunotherapy options have been performed, early initiation of PE prior to IVIG may provide better outcomes. A long-term follow-up conducted by Pham et al. showed that patients treated with IVIG after PE had better outcomes than those who received IVIG prior to PE (Pham et al., 2011). In addition, PE can remove the autoantibodies quickly, resulting in rapid symptomatic improvement in severe cases of anti- NMDAR encephalitis. Because patients with severe anti- NMDAR encephalitis may suffer from autonomic instability, it is important to evaluate whether they can tolerate PE procedures, and their vital signs must be closely monitored during therapy. Recently, a study divided patients with severe refractory anti-NMDAR encephalitis into a PE group and a non- PE group. The PE group showed greater improvement in clinical symptoms than the non-PE group after 1 month and 2 months following treatment (Zhang et al., 2019), suggesting that early use of PE may be a better treatment option. Agitasi Agitation, atypical sedating antipsychotics (such as olanzapine) are preferable because they induce fewer side effects, such as NMS and extrapyramidal symptoms (EPS), which can worsen agitation. Moreover, olanzapine has been shown to prevent toxicity associated with NMDAR antagonists in animal experiments. Clonidine may help reduce agitation through regulation of the autonomic nervous system. Gejala Lain Typical and atypical antipsychotics have been administered alone or in combination to treat hallucination and delusion (Kuppuswamy et al., 2014). Lithium and valproic acid areprimarily used to control manic symptoms. Owing to its anti- epileptic and mood stabilizing properties, valproic acid can be used to effectively treat mood symptoms. Furthermore, valproic acid can be used to treat choreiform movements and dyskinesia, which are commonly observed in anti-NMDAR encephalitis Implikasi Klinis Anti-NMDA receptor encephalitis is a relatively newly identified and potentially treatable cause of psychiatric symptoms. To date, the recommendation for screening has advised testing of those patients, particularly females, with an atypical new-onset presentation of psychosis with motor features. It is clear that early identification and treatment may have serious prognostic implications. Delay to treatment with immunosuppressive therapy probably results in worsened outcomes, with evidence for permanent hippocampal damage. Anti-NMDA receptor encephalitis is a potentially treatable form of psychiatric illness that is illuminating our understanding of the neuropathophysiology involved in some individuals who present with symptoms of psychosis. Differential Diagnosis Clinical symptoms of anti NMDAR encephalitis may mimic schizophrenia and psychotic spectrum disorders. New onset psychosis typically occurs in late teens to 30s. Females generally present at a later age than males. There is often a family history of mental illness, but this is not always the case. Many patients with schizophrenia do not have insight into their illness. For example, they are less likely to view their hallucination as such and instead are likely to incorporate them into delusional thoughts. In our experience, our patient had insight into her cognitive decline. At times, she seemed to be pleading for helpwhile acknowledging her thoughts were disordered by nodding. Abnormalities in CSF and autoantibodies can occur in individuals with schizophrenia as well as those with antiNMDAR encephalitis. Elevated inflammatory cytokines, immunoglobulins, and elevated cell counts within the CSF have been noted in 40-70% of individuals with schizophrenia and affective psychosis. The differential diagnosis also includes other viral encephalitides (cytomegalovirus [CMV], Epstein-Barr, herpes simplex virus [HSV], varicella zoster virus [VZV], human immunodeficiency virus [HIV], human herpesvirus 6 [HHV6]/ human herpesvirus 7 [HHV7], arbovirus, rabies virus), other autoimmune causes (limbic encephalitis, other paraneoplastic encephalitides, systemic lupus erythematosus, antiphospholipid syndromes, Sjégren’s syndrome, Graves’ disease, Hashimoto's encephalitis, vasculitis), and toxic/ metabolic disorders (drug ingestion, porphyria, mitochondrial disorders). When antipsychotics have been used for initial presenting symptoms, neuroleptic malignant syndrome enters the differential. It may be difficult to differentiate this from the autonomic symptoms seen in anti-NMDAR encephalitis. In our experience, we found patients with anti-NMDAR encephalitis to be less responsive to typical antipsychotic treatments. NEOS The score was strongly associated with the probability of poor functional status at 1 year (3% for 0 or 1 point to 69% for 4 or 5 points).36 This may be of use to the provider when discussing prognosis with family members, whereas, in the past, these discussions may have been more nebulous. Of note, the authors found that of patients in their cohort with poor functional status at 1 year, 35% of them recovered to good functional status at 2 years.