Depressionen und Psychosen bei immunologischen Enzephalopathien

Kernaussagen

Bei akuten bzw. subakuten kognitiven Defiziten in Kombination mit weiteren neuropsychiatrischen (Wahn, Halluzinationen, Ich-Störungen, Depression) bzw. zusätzlichen neurologischen Symptomen (epileptische Anfälle, Myoklonien, Bewegungsstörungen, fokal neurologische Symptome) sollte differenzialdiagnostisch auch an eine immunologische Enzephalopathie gedacht werden. Aber auch klassische Präsentationen im Sinne von Depressionen oder Psychosen können durch immunologische Enzephalopathien verursacht werden. In Zusammenschau von Labor-, Bildgebungs- (MRT, ggf. FDG-PET), EEG- und Liquorbefunden kann die Diagnose einer immunologischen Enzephalopathie gestellt werden. Insbesondere dem Nachweis von Antikörpern gegen neuronale Zelloberflächenantigene oder intrazelluläre synaptische/onkoneuronale Antigene kommt eine wesentliche Bedeutung zu. Eine Tumorsuche und ggf. Behandlung ist in vielen Fällen angezeigt. Eine Tumorresektion kann in solchen Konstellationen eine genuin kausale Therapie der neuropsychiatrischen Symptomatik darstellen. Immunmodulatorisch kommen eine hoch dosierte Steroidbehandlung, Plasmapherese oder intravenöse Immunglobuline (First-Line) zum Einsatz. Bei fehlendem Ansprechen können Behandlungsversuche mit Rituximab oder Cyclophosphamid (Second-Line) erwogen werden.

Das Erkennen von immunologischen Enzephalopathien im psychiatrisch-psychotherapeutischen Alltag ist wichtig, da

• potenziell lebensbedrohliche Erkrankungen vorliegen,

• oftmals eine Tumorassoziation besteht,

• eine im Vergleich zur klassischen psychiatrisch-medikamentösen Behandlung unkonventionelle bzw. innovative Behandlungsoption (Immuntherapie) vorliegt und

• diese Erkrankungen unter adäquater Behandlung potenziell reversibel sind.

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