Autoimmune Encephalitis in Later Life: A Missed Opportunity in Routine Geriatric Care

TL;DR

Autoimmune encephalitis in older adults is often missed, but early detection through functional imaging and treatment can improve outcomes.

Contribution

Highlights the importance of functional neuroimaging and clinical suspicion in diagnosing autoimmune encephalitis in elderly patients.

Findings

An elderly patient with delirium showed hypermetabolic brain activity suggestive of AE despite negative initial tests.

Treatment with corticosteroids and plasma exchange led to significant clinical improvement.

Functional imaging proved valuable in diagnosing AE when conventional tests were inconclusive.

Abstract

Autoimmune encephalitis (AE) is an increasingly recognized but frequently overlooked cause of subacute cognitive and behavioral decline in older adults, in whom delirium is typically attributed to metabolic, infectious, or vascular disorders. We describe an elderly man who presented with persistent encephalopathy following correction of hyponatremia. Despite normal structural neuroimaging and negative cerebrospinal fluid autoimmune markers, he remained delirious. Electroencephalography revealed diffuse slowing, and fluorodeoxyglucose positron emission tomography demonstrated characteristic hypermetabolic activity involving the temporal lobes, basal ganglia, thalami, and cerebellum, strongly suggestive of AE. Initiation of high-dose corticosteroids followed by therapeutic plasma exchange resulted in marked clinical improvement. This case highlights the diagnostic complexities of AE in geriatric practice, particularly the limitations of conventional testing and the value of clinical suspicion backed by functional neuroimaging. Greater clinical vigilance is required to avoid delayed diagnosis and treatment, which may substantially improve outcomes even in severe presentations.

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