Functional and cognitive recovery after intensive care unit-initiated intensive rehabilitation in anti–N-methyl-D-aspartate receptor encephalitis: A long-term case report
Yongwun Cho, Hyunggi Park, Young-Soo Kim, Hayoung ByunRationale:
Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a severe autoimmune encephalitis that can result in prolonged coma, ventilator dependence, and long-term disability. Although immunotherapy is well established, the optimal timing and intensity of rehabilitation remain poorly defined. This report describes a rare case of adult anti-NMDAR encephalitis with profound neurological impairment who achieved remarkable functional and cognitive recovery following intensive, goal-oriented rehabilitation initiated while still in the intensive care unit (ICU).
Patient concerns:
A 35-year-old woman with prior thyroid carcinoma and ovarian teratoma presented with fever, confusion, and behavioral changes progressing to decreased consciousness. She remained comatose for months despite extensive immunotherapy and supportive care.
Diagnoses:
Anti-NMDAR encephalitis was confirmed by the detection of anti-NMDAR antibodies in both serum and cerebrospinal fluid. Neuroimaging excluded other causes of encephalopathy.
Interventions:
The patient underwent sequential immunotherapy including high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange, followed by rituximab, tocilizumab, and cyclophosphamide. After nearly 20 months of medical instability, she began intensive multidisciplinary rehabilitation—five sessions per week, 2 hours daily—while still in the ICU. Therapy targeted progressive mobilization, upper-limb activation, and communication training, delivered under continuous cardiorespiratory monitoring.
Outcomes:
Over 3 months, substantial improvement was observed: Modified Barthel Index increased from 0 to 72, Berg Balance Scale to 42, Mini-Mental State Examination to 9, and Manual Function Test to over 80 bilaterally. She achieved independent ambulation and daily self-care, with significant gains in language function. The patient reported high satisfaction with her regained independence and ability to resume normal activities, and no adverse events occurred during rehabilitation.
Lessons:
This case demonstrates that active, structured rehabilitation can be safely implemented even in medically complex, prolonged cases of autoimmune encephalitis. Intensive, goal-directed therapy under ICU monitoring may promote late neuroplasticity and yield meaningful recovery long after disease onset. Rehabilitation should be considered an an integral therapeutic component alongside immunotherapy in the long-term management of severe anti-NMDAR encephalitis.