A fictional 23-year-old develops rapidly progressive insomnia, paranoia and disorganised behaviour, followed by seizures, orofacial dyskinesia and fluctuating heart rate. MRI is unremarkable; CSF shows a mild lymphocytic pleocytosis.
Listen for the assumption.
The MRI is normal and the presentation began with psychosis, so I thought this was primarily psychiatric.
Rapid progression with seizures, abnormal movements and autonomic change is an encephalitis syndrome until proved otherwise. Infection and autoimmune causes must be investigated in parallel.
I will continue time-critical encephalitis management, send paired serum and CSF neuronal antibodies, involve neurology and critical care, and screen for an associated tumour.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- New seizures and prominent orofacial dyskinesia
- Heart-rate variability suggesting autonomic involvement
- Unremarkable MRI does not explain the evolving syndrome
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Protect airway and breathing, manage seizures and agitation safely, monitor autonomic instability, and follow the local encephalitis pathway while urgent specialist advice is obtained.
Discuss immunotherapy timing with neurology after appropriate sampling and exclusion work. If a relevant tumour is found, coordinate treatment promptly, but do not claim tumour absence excludes the diagnosis.
I will hand over the symptom sequence, seizure and autonomic burden, infection cover, CSF/EEG/imaging findings, antibody samples and tumour-screening plan.
What must remain explicit.
- Follow the local encephalitis and seizure pathways.
- Do not delay stabilisation or appropriate empirical infection treatment while awaiting antibody results.
- Use neurological and critical-care expertise for immunotherapy, autonomic instability and tumour screening.
Where reasoning fails.
- Diagnostic overshadowing by psychiatric symptoms
- Using normal MRI to exclude encephalitis
- Treating antibody results without clinical correlation
Rapid encephalitis syndrome with behaviour/cognition [timeline], seizures/movements [details], airway/autonomic status [trend], infection cover [details], CSF/EEG/MRI [summary], antibodies [sent/time] and tumour screening/specialist plan [details].
Which combination of psychiatric and neurological features should trigger your medical encephalitis pathway?