Personality Changes After Encephalitis: When 'Organic Personality Disorder' Is Not Enough

F.C. is a previously healthy 21-year-old female presenting a challenging emotional and behavioral disorder starting at the age of 19. At that age, while attending university, she started complaining of concentration difficulties. Subsequent ophthalmoplegia with bilateral ptosis, abnormal jaw movements, and difficulties in swallowing prompted neurological evaluation. Brain magnetic resonance imaging (MRI) revealed large bilateral lesions in deep brain structures (Fig. 35.1). Cell count in cerebrospinal fluid (CSF) was 16 lymphocytes. One single CSF sample was positive for anti-GAD testing (Oxford Laboratory), but following tests remained negative for this or other antibodies, as well as an extensive inflammatory, infectious, and neoplastic workup. Autoimmune encephalitis was suspected. Initial treatment was administered in the intensive care unit because of altered level of consciousness. It involved high-dose corticoid therapy, plasma exchanges, and intravenous immune globulins. Clinical evolution was satisfactory with rapid improvement of neurological symptoms. The first behavioral changes occurred during the intensive care unit (ICU) stay in the form of stereotypic handwashing without intrusive thoughts, hyperphagia, and akathisia. Three weeks after admission, she was transferred to a neurological ward and discharged after 2 further weeks.