A 34 year old right handed male was admitted with a one day history of stuttering speech on a background of three months of low mood, sleep disruption, headaches and sweats. He developed writhing mouth movements, visual and auditory hallucinations and severe hypertension with sinus tachycardia. He acutely deteriorated with central apnoeas and generalised seizures necessitating intubation and ventilation. Cerebrospinal fluid examination revealed a lymphocytic pleocytosis; infective and systemic autoimmune blood and CSF screening yielded no abnormalities. An empirical diagnosis of autoimmune limbic encephalitis was made and intravenous steroids commenced. Body imaging revealed two testicular nodules in a small testis. A paraneoplastic syndrome was suspected; urgent orchidectomy was considered but the patient was unable to provide consent.
Multidisciplinary opinions were sought from neurology, urology, oncology, immunology, radiology and legal advisors. After discussion with the patient's family, a best-interests decision was taken to remove the testis and he was given intravenous immunogobulins. Testicular histology showed atrophy and fibrotic nodules but no malignancy. Tests for common onconeural and neuronal surface antibodies were negative. The patient made a rapid recovery, returning to independent living in one month and resuming his usual work in a further three months, on a reducing oral steroid regime.