J Clin Gynecol Obstet

Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc

Journal website https://www.jcgo.org

Case Report

Volume 10, Number 1, March 2021, pages 22-27

Ovarian Teratoma and N-Methyl-D-Aspartate Receptor Autoimmune Encephalitis: Insights Into Imaging Diagnosis of Teratoma and Timing of Surgery

**Table 1.** Summary of Cases
	Case 1	Case 2	Case 3	Case 4
CSF: cerebrospinal fluid; NMDAR: N-methyl-D-aspartate receptor; PCR: polymerase chain reaction; EEG: electroencephalogram; MRI: magnetic resonance imaging; CA125: cancer antigen 125; AFP: alpha fetoprotein; hCG: human chorionic gonadotropin; LDH: lactate dehydrogenase; CEA: carcinoembryonic antigen;
Age	38	17	26	28
Parity	2	Nulliparous	2	2
Time since symptoms to referral	26 days	43 days	38 days	180 days
Fever	+	+	+	-
Abnormal psychiatric symptoms behavior	+	+	+	+
Speech disorder	+	+	+	+
Seizure	+	+	+	-
Movement disorder	+	+	+	+
Loss of consciousness	-	-	-	-
Autonomic dysfunction	+	+	+	-
Modified Rankin score	5	5	5	4
CSF analysis
Count	6/mm³	3/mm³	14/mm³	1/mm³
Glucose	73 mg/dL	55 mg/dL	82 mg/dL	66 mg/dL
Protein	36 mg/dL	21 mg/dL	25 mg/dL	61 mg/dL
CSF PCR for viruses	Negative	Negative	Negative	Negative
CSF culture	Sterile	Sterile	Sterile	Sterile
NMDAR antibodies in CSF	2+	2+	2+	Negative
NMDAR antibodies in blood	Not done	2+	Not done	Negative
EEG	Bihemispheric slow wave	Bihemispheric slow waves	Bihemispheric slow wave	Not done
MRI brain	Normal	Diffuse cerebral edema	Diffuse cerebral edema	Normal
Medical treatment	Methylprednisolone, IVIG, rituximab	IVIG initially, methylprednisolone throughout, later plasmapheresis, rituximab, bortezomib	Methylprednisolone, rituximab	Plasmapheresis, methylprednisolone, rituximab
Need for tracheostomy	Day 40 of symptoms	Day 10 of onset of symptoms	7 days after symptom onset	No

Period of hospital stay	53 days	180 days	36 days	28 days
Neurological outcome
Follow-up time	32 months	25 months	19 months	4 months
NMDAR	Negative	2+	Negative
Modified Rankin score	0	5	0	1
Imaging modality	PET-CT	USG, CT, MRI	USG	PET-CT
CA-125	Not done	10.40	15.8	8.92
b-hCG	1.4	< 0.100	< 0.100	< 0.100
CEA	Not done	0.67	3.01	Not done
AFP	2.77	Not done	1.9	1.4
LDH	798	Not done	503	358
Type of surgery	Laparotomy BSO	Laparoscopic RSO	Laparotomy RSO, left cystectomy	Laparoscopic RSO
Anesthesia	General anesthesia	General anesthesia	General anesthesia	General anesthesia
Timing of surgery from date of admission	22 days	5 days	4 days	21 days
HPE report	B/L mature ovarian teratoma	Mature cystic teratoma: right ovary	B/L mature cystic teratoma	Mature cystic teratoma
Bilaterality	+	-	+	-
Size of the tumor	Right cyst: 3 × 3 × 2cm, left cyst: 4 × 3 × 2 cm	Ovary: 2.6 × 1.5 × 1 cm; 3 cystic spaces 0.3 - 0.6 cm with hair	Right: 2 × 1 cm, left: 2 × 1.5 × 0.7 cm	Cyst: 5 × 3 cm

Table 1. Summary of Cases

Case 1

Case 2

Case 3

Case 4

CSF: cerebrospinal fluid; NMDAR: N-methyl-D-aspartate receptor; PCR: polymerase chain reaction; EEG: electroencephalogram; MRI: magnetic resonance imaging; CA125: cancer antigen 125; AFP: alpha fetoprotein; hCG: human chorionic gonadotropin; LDH: lactate dehydrogenase; CEA: carcinoembryonic antigen;

Age

Parity

Nulliparous

Time since symptoms to referral

26 days

43 days

38 days

180 days

Fever

Abnormal psychiatric symptoms behavior

Speech disorder

Seizure

Movement disorder

Loss of consciousness

Autonomic dysfunction

Modified Rankin score

CSF analysis

Count

6/mm³

3/mm³

14/mm³

1/mm³

Glucose

73 mg/dL

55 mg/dL

82 mg/dL

66 mg/dL

Protein

36 mg/dL

21 mg/dL

25 mg/dL

61 mg/dL

CSF PCR for viruses

Negative

CSF culture

Sterile

NMDAR antibodies in CSF

Negative

NMDAR antibodies in blood

Not done

Negative

EEG

Bihemispheric slow wave

Bihemispheric slow waves

Bihemispheric slow wave

Not done

MRI brain

Normal

Diffuse cerebral edema

Normal

Medical treatment

Methylprednisolone, IVIG, rituximab

IVIG initially, methylprednisolone throughout, later plasmapheresis, rituximab, bortezomib

Methylprednisolone, rituximab

Plasmapheresis, methylprednisolone, rituximab

Need for tracheostomy

Day 40 of symptoms

Day 10 of onset of symptoms

7 days after symptom onset

Period of hospital stay

53 days

180 days

36 days

28 days

Neurological outcome

Follow-up time

32 months

25 months

19 months

4 months

NMDAR

Negative

Modified Rankin score

Imaging modality

PET-CT

USG, CT, MRI

USG

PET-CT

CA-125

Not done

10.40

15.8

8.92

b-hCG

1.4

< 0.100

CEA

Not done

0.67

3.01

Not done

AFP

2.77

Not done

1.9

1.4

LDH

798

Not done

503

358

Type of surgery

Laparotomy BSO

Laparoscopic RSO

Laparotomy RSO, left cystectomy

Laparoscopic RSO

Anesthesia

General anesthesia

Timing of surgery from date of admission

22 days

5 days

4 days

21 days

HPE report

B/L mature ovarian teratoma

Mature cystic teratoma: right ovary

B/L mature cystic teratoma

Mature cystic teratoma

Bilaterality

Size of the tumor

Right cyst: 3 × 3 × 2cm, left cyst: 4 × 3 × 2 cm

Ovary: 2.6 × 1.5 × 1 cm; 3 cystic spaces 0.3 - 0.6 cm with hair

Right: 2 × 1 cm, left: 2 × 1.5 × 0.7 cm

Cyst: 5 × 3 cm