Quijotemd

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I have a 41 yo female patient now in the hospital with a past psychiatric history significant for post-partum depression 15 years ago, which reportedly resolved in a month without meds, who presents with a 3 day h/o hearing multiple voices. She looks very depressed, appears to lack energy, can barely get up enough motivation to answer a question, and when she does, can barely speak loud enough to hear. She has an odd, shuffling gait and wanders around the ward aimlessly. According to her son, she was a very different person 4-5 days ago--talkative, much more energetic, and fairly happy--and then 3 days ago began to look very depressed, sad, wouldn't get out of bed, and then began to hear voices and looked internally preoccupied. No h/o illnessnes, no drug use history, but she is a distributor of Herbalife and I was told takes it often. He is going to bring me the bottle tomorrow but does this presentation sound familiar to anyone? When I do a search I get hits for ephedra-induced psychiatric illness. I wonder if this could have caused the abrupt change in this woman, even though she'd been taking the stuff for months. I am awaiting UDS....would ephedra make the amphetamine screen positive? Any suggested tests to order? I plan to get a CT scan to r/o mass. Any other thoughts?

Thanks!

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Solideliquid

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Rule out the axis III conditions: MRI w/ and w/o contrast (may show encephalitis and/or meningitis) among other things. EEG, EKG, chest x-ray, folate, b-12, RPR, HIV, U/A, UDS, CBC w/diff and CMP.
Do a full neuro exam and consider a neuro consult for a tap if everything else is negative.

You will also want to get an extensive history, talk to family members who knew the patient in her 20s. Did she ever act odd or behave strangely before? She may have had a psychotic disorder (schizophrenia, etc) when she was younger but dealt with it in her own way. Or she may be having late onset schizophrenia. OR it could be something she has been taking but the fact that she's been taking it for months (lol they practically make you eat all that junk if you work for Herbalife) and no symptoms make that a strange coincidence.

Consider paraneoplastic syndrome, we recently had an interesting Grand Rounds where the speaker had several patients with psychotic symptoms when a teratoma was found and removed from the pelvis. Consider that as a distant differential. Pts got better when the tumor was removed.
 

whopper

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Checked out the Herbalife website and its not exactly making the ingredients very specific.

However any stimulant based diet aid can cause psychosis.

Based on the sx you're mentioning I'd definitely consider this in the differential dx, but I'd also factor in some other things as well. The shuffling gait seems wierd & not consistent with a stimulant induced psychosis if this is one or a different concurrent problem.

I know this is a zebra but schizophrenia in females, though rare can start in the 40s.
 
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Anasazi23

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Not saying this is what she has, but just FYI...

I've had a few patients with diet-pill induced psychosis, and many more who are known to have psychotic episodes, which were greatly exacerbated by taking said diet pills.

If you say that she has already manifested a diathesis at some point (post partum depression...are you sure it wasn't psychosis, or pregnancy-induced psychosis?), then it seems there is a higher liklihood that she may be experiencing this.

Our laboratory claims that diet pill ingestion won't run positive for amphetamines, but I can't claim to know the science behind this. We'd have to look up the metabolites of this stuff, and get to know in more detail how the u-tox machine determines a positive result.

But like was mentioned above, I'd do a thorough organic rule-out also.
 

Quijotemd

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Thanks for all the wonderful input, everyone. I love this forum! Well, my patient cleared up in about four days, on 1mg of risperdal BID. But perhaps she would have cleared anyway even without the meds, but maybe a slower recovery. All the workup was negative, basic labs, RPR, UDS, HIV, CT, etc. She will follow up with me in my outpatient clinic and I told her to bring all the bottles of the herbs she had taken. Would this be worth a case report or is it too common to be worth writing up?

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sdn1977

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My very own, small opinon is this is anectodal evidence only which we have in abundance on herbs.

We are looking to find well designed double blind studies on herbs. So far, most of them end up as dead ends (ie - garlic) so there is very little funding for well run studies.

Good luck & glad she cleared up for whatever reason!
 

whopper

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The problem I have with diet studies and humans is that human subjects have very variable diets.

When in grad school, I changed diets on rats to see effects. E.g. in increase the salt, you see higher BP and higher rates of stroke.

But with humans, you don't know what the heck they eat after they leave your office. Even if they tell you what they eat, its often times inaccurate.

IMHO to do a very good study to see if diet were to make a difference, you'd have to force the subject to only eat what you gave them, and hardly any subject would volunteer for such a study.

So when it comes to diet, if something showed a significant effect and it was done on humans, IMHO, it strongly implies that the effect is probably very very strong, and likewise, unfortunately dietary differences that have subtle to moderate effects probably may not ever show up on a study involving human subjects.

Reason why I think its relevant to this topic, is I bet a lot of the "holistic" stuff may have a benefit but its not going to be gauged well because of variability in diet. When you got 100 patients all eating very different things, its going to mess with the results of a study on a holistic approach.
 
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