Interesting case.

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50 y/o woman with no history or family hx of psychiatric problems, has an episode of idiopathic elevated BP, and is admitted under normal protocol. BP subsides, but within 72hours the patient develops psychotic symptoms (visual and auditory hallucinations primarily at night, and persistent paranoia), global amnesia, but more pronounced retrograde, severe social phobia, persistent agitation and akathisia-like sx where she cannot physically sit still for more than a few minutes. She was put on zoloft 50 mg qam, klonopin .25 tid and .5 qhs. After she was released from the hospital with a clean MRI and CT, she was tried on seroquel 25-100 mg qhs, but stopped taking it after 3 nights of severe agitation. I changed her klonopin to .5 mg bid, d/c'd the zoloft, and added 10 zyprexa qhs, with some PRN lunesta so she can sleep a few hours. She is less agitated, but still has active psychotic features (w/o thought disorder), and global amnesia...she had no memory of me, my office, the hospital etc..after one week. All labs are normal. Pt is being followed in primary care.
 
She may have had a small (or series of small) TIA, obviously with some permanent symptoms. My question is, is it safe for this patient to be followed as an outpatient? Is she at least in a NH now?

EDIT: Also, lunesta is probably not a good choice for geri patients. You may think about switching her to Trazodone 25-50mg QHS? According to our Geri attending, "benzos have no place in the care of geriatric patients."
 
What's her medical Hx? Is she on any other meds for BP or other?
 
Lunesta is not a benzo, and she is hardly gero at 50. She is being cared for by her parents for now.
 
psisci said:
Lunesta is not a benzo, and she is hardly gero at 50. She is being cared for by her parents for now.
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It interacts at the GABA receptor. Also she is on klonopin, regardless of her age, she seems to be presenting at the level of a demented geri patient.

She can't care for herself and she is possibly a danger to herself because of her mental status. She may need the 24/hr care of a NH. That's all I'm saying.

It is very hard to have a meaningful discussion without seeing the patient and reviewing the history.

Edit: Give us some more from the MSE: how is her speech, is she displaying loose associates/disorganization? What are her psychotic symptoms? Have you considered something like Depakote/Lamictal/Topomax?
 
I said she has no s/s of a though disorder. Her psychotic sx are positive only. This was an acute onset. Etoh interacts with GABA receptors, but is not a benzo by any means.
 
How about her social history?

Any drug or etoh use?
What's her living/financial situation like?
Any suspicion that she would want to hide any of this information from you?

I'm reachign here, but: any raw meat in her diet?
[Based on the time frame and some recovery of function, a prion-mediated encephalopathy is almost certainly ruled-out, but hey it's worth a shot]

Also, what was the reason for presentation initially?
Was the htn picked up on routine BP check, or was she symptomatic -- if so, what were her sxs?
 
Yes, metoprolol but I think I said that in my intro. What about social Hx do you want? I am very interested in your expertise, so shoot any ?'s you have out, and I will do what I can to answer them...

Come on Sazi...😉
 
psisci said:
No UDS yet...why?
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I hope they did a UDS when she was admitted.

Maybe she did a bunch of coke or god knows what else and fried her brain?

On the other hand, was her BP > 220/120 or something crazy like that? Why was she admitted for hypertension?

EDIT: Case in point: We had a 55 yo M admitted to the psych ward this week from his PCH. Agitated behavior, screaming at the owner and throwing plates. Dx schizophrenia, was he off his meds, what was going on? Responding to internal stimuli on the ward. On Seroquel 200 mg qam and 300 mg qpm. Gave him an extra 20mg Geodon PO in the afteroon on day 1 of his admission. Next day feeling better, no A/V H. Was discharged to a different PCH as the owner doesn't want him back. Check UDS? Yes boys and girls. PCP. Snap.
 
Why does a lady with no psych history get placed on zoloft for 72 hours of psychotic symptoms? What you're calling "severe social phobia" sounds more like acute paranoia as a feature of a generalized delirium. Keep working the antipsychotics and find and treat the underlying cause.

How sure are you about the "clean MRI"? I betting on some kind of badness in the temporal lobes...
 
OldPsychDoc said:
Why does a lady with no psych history get placed on zoloft for 72 hours of psychotic symptoms? What you're calling "severe social phobia" sounds more like acute paranoia as a feature of a generalized delirium. Keep working the antipsychotics and find and treat the underlying cause.

How sure are you about the "clean MRI"? I betting on some kind of badness in the temporal lobes...
Click to expand...

The neuro who consulted saw nothing on the MRI, but we are repeating it. I agrre with the acute paranoia explanation. I have no idea why zoloft was started. Social hx unremarkable.
 
"Idiopathic" blood pressure elevation isn't a satisfactory diagnosis. Something was missed or she has a history.

She's delirious and her med regimen is more than suboptimal.
 
We can all second guess what the doctors who treated her did or did not do, dx etc, but these are the facts as they were presented to me. Any ideas what would cause this group of symptoms with such a rapid onset?
 
Anything from renal artery stenosis, to carcinoid, late onset schizophrenia, subacute infarct, pseudoxanthoma elasticum, hypoplasia of the descending aorta, to essential hypertension. The point is that a thousand things can cause hypertension...

Delirium can and almost by definition is rapid onset.

Always be leary and be damn sure you've ruled out organic causes when presented with visual hallucinations and sundowning.
 
what did the lumabr puncture show?
 
Lumbar happens next week. I am not too concerned with what caused the HTN as that is someone else's role. I do feel this is a physiological condition and not late onset psychosis et al. Repeat MRI happens next week as well as a f/u with Neuro.
 
I agree that a neuropsych eval would be nice, but not possible due to $ concerns. Delerium secondary to what??? Rememebr this person was perfectly functional until her last admission in Sept. Her memory is intact for incidents that happened prior to the admission, but she is not making many new long-term memories unless they are emotionally loaded. Her paranoia and memory problems are the most troubling. The visual and auditory hallucination happen only at NOC. I got an EEG ordered, but if nothing is happening at the time that will tell us nothing, and we can't do a 24hr EEG unless she needs to get admitted again. Her ID is carefully concealed.
 
Syphilis...Lyme disease? This is like House, PhD. lol
 
I would like to add to Sazi's differential : Lewy Body Dementia
 
psisci said:
I agree that a neuropsych eval would be nice, but not possible due to $ concerns. Delerium secondary to what??? Rememebr this person was perfectly functional until her last admission in Sept. Her memory is intact for incidents that happened prior to the admission, but she is not making many new long-term memories unless they are emotionally loaded. Her paranoia and memory problems are the most troubling. The visual and auditory hallucination happen only at NOC. I got an EEG ordered, but if nothing is happening at the time that will tell us nothing, and we can't do a 24hr EEG unless she needs to get admitted again. Her ID is carefully concealed.
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Suspicious for something to happen "Only in NOC's as well - can usually be a sign of 1. malingering, 2. "illusions" caused by decreased light (can she SEE? haha) and with the quick onset of AMS with psychotic symptoms, I'm going with TIA's and possibly Lew Body Dementia - interesting, but in my short OH SO SHORT time on psych - I've seen some crazy malingering already 😱
 
Jon Snow said:
"I would like to add to Sazi's differential : Lewy Body Dementia"

generally too young and it's acute. . .
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is it too young? I thought you can have an early onset Lewy Body dementia... anyone? I'm not convinced TIA's alone can give you psychosis, but I'm new so I don't know.

What about ETOH dementia?
 
We may never know if they didnt check a UDS and an etoh level on admission.
 
cns lymphoma or carninomatous leptomeningitis

autoimmune perhaps............................ such as lupus cerebritis

I would have tapped her by now, since viral encephalitis and other processes won't show on MRI "clean" or not. I tapped many patients during both my psych and neuro rotations..why didn't you just do a LP and send it off for serologies, etc.?
 
This is not Etoh, and Yes Snow you egg-head it is anterograde. The amnesia is one thing, but the presence of the paranoia, and hallucinations q-noc is very abnormal. TLE is possible, but delerium...nope. What about pick's disease?

House PhD
 
This sounds like the blind men touching the elephant and each giving a different description.

This isn't how a differential is built or investigated.

Points:

You can have late onset schizophrenia - more common in females.

You can have Lewy Body at that age. It can present as semi-acute.

Drug effects can last weeks years after the ingestion. No nystagmus, focal neuro signs, gait ataxia, nor response to B1 infusion was reported or described.

Talking about retrograde vs. anterograde, etc. is largely academic pontification. Studies on delirium (assumption) demonstrate that a significant proportion of the patients have memory disturbance throughout the duration (though not the majority). It still isn't treated properly.

"Delirium secondary to what?" --> It's hard to make a medical diagnosis on someone we have virtually no information on. We didn't work her up. Oftentimes the cause is not determined. But it sounds like a full workup was not done. Letting someone with new onset psychosis and visual hallucinations out of the hospital without an eeg is criminal.

"Happens at NOC?" Northrup Grumman? Nippon Oil corporation? Is that supposed to mean nighttime?

LP was also essential here. Should have been done in the ER or on the floor.

"Would they not be going through withdrawals by now if it was etoh (korsakoff's) causing a persistent problem like this?"
Not two weeks later.

The basics haven't been done. So all this guessing is of limited value.
 
Anasazi23 said:
This sounds like the blind men touching the elephant and each giving a different description.

This isn't how a differential is built or investigated.

Points:

You can have late onset schizophrenia - more common in females.

You can have Lewy Body at that age. It can present as semi-acute.

Drug effects can last weeks years after the ingestion. No nystagmus, focal neuro signs, gait ataxia, nor response to B1 infusion was reported or described.

Talking about retrograde vs. anterograde, etc. is largely academic pontification. Studies on delirium (assumption) demonstrate that a significant proportion of the patients have memory disturbance throughout the duration (though not the majority). It still isn't treated properly.

"Delirium secondary to what?" --> It's hard to make a medical diagnosis on someone we have virtually no information on. We didn't work her up. Oftentimes the cause is not determined. But it sounds like a full workup was not done. Letting someone with new onset psychosis and visual hallucinations out of the hospital without an eeg is criminal.

"Happens at NOC?" Northrup Grumman? Nippon Oil corporation? Is that supposed to mean nighttime?

LP was also essential here. Should have been done in the ER or on the floor.

"Would they not be going through withdrawals by now if it was etoh (korsakoff's) causing a persistent problem like this?"
Not two weeks later.

The basics haven't been done. So all this guessing is of limited value.
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Great to see your TP Sazi, Im with you on the basics of LP, MRI, EEG and labs to R/O medical condition. Thanks for the info on Lewy Body, I had thought when I was on neuro he said you can have an early onset because we worked a really young guy up and that was one of his differentials.

Also, what do you make of these hallucinations at night? How is her visuospatial testing? You could do that simple drawing and see if perhaps it points toward Alzheimers. On neuro I learned that if they have a heavy predisposition they can have a very early onset - that would account for paranoia - is she paranoid with family? I suppose with Alzheimers you could have a sundowning presentation - but usually not so acute like this woman... but is she really acute?

Jon, I think that she would be out of the withdrawal period by now for risk of DT's - and from what I learned on addictions, only 15% of all alcoholics will actually go into DT"s 85% of people treated are not - but we do it, because its life threatening for those that will go through it. And the biggest predictor of going into DT's is sig. hx of DT's in the past.

Psici, can we have a medical hx, family hx and substance hx?

Poety2, because Poety is gone forever 😛
 
Poety2 said:
Also, what do you make of these hallucinations at night? How is her visuospatial testing?
Click to expand...

New onset visual hallucinations are organic until proven otherwise. In this case, it hasn't been proven otherwise yet.

The horse here is delirium. The zebras are the seizure disorders, dementing processes, etc. It isn't treated correctly pharmacologically, so it's even harder to tell. Obviously without examining her it's impossible to tell.
 
Jon Snow said:
Herpes encephalitis? It's possible for the MRI to be normal if you caught it early enough. Has her condition worsened?
Click to expand...

I'm going to reiterate the possibility of hsv or other viral enchephalitis. Doesn't necessarily explain htn but htn itself is quite common. She should have had an LP before being D/C. Need to do encephalitis panel for all of the arboviruses etc. and of course PCR for HSV. Red cells in the CSF are also classic of HSV. What was the justification for d/c without a diagnosis?

it's hard to resist, but should we really be talking about this on a public message board??
 
Sometime the dx has to be NOS...when you can't find a clear etiology.

Dementia NOS I suppose?
 
Jon Snow said:
. . .actually not, especially if one is considering maligering in your differential. . . or TBI. . . or any number of conditions really.

dementia with lewy bodies as an early onset would stay on the differential list, but low probability at that age. . .
Click to expand...

If the woman's sitting in your office delirious (assumption), there's not a lot of utility in fettering out nuances in memory processing. In that case, it's not that she's got "anterograde amnesia." It's that she's delirous and can process virtually no information effectively. To focus on a memory deficit is looking at the trees and missing the forest. A mistake in medicine.
 
I disagree. She is oriented, and can process information well; it is not delerium. She is just not creating any new LTMs.
 
psisci said:
I disagree. She is oriented, and can process information well; it is not delerium. She is just not creating any new LTMs.
Click to expand...

Well, you don't see her at night. By definition the condition waxes and wanes, so you cannot rule out delirium.

Bah....trying to make diagnoses over the internet is impossible.

Who knows, I could take one look at her and know the diagnosis, or it could be a rare zebra that nobody could have predicted.

Grand rounds time. Gotta go.
 
I'm going with Sazi on this one. Point of waxing and waning, and you not seeing the patient consistently. Patients are often reoriented periodically throughout the day, so just because they are a+ox4 now after being reoriented an hour ago, doesn't mean in 3 hours they won't forget it all and only be oriented to self again.

The delirium is still big in the picture. How are her caretakers describing her course? Waxing and waning? Always bad? When I first read the idiopathic BP elevation followed by psychotic sx's I'm definitely thinking withdrawl- etoh or something else.

How have her vitals been throughout? During her hypertensive urgency episodes, how was her temp?

as for TIA's (meaning vascular dementia, right? What are her risk factors? TIA's causing psychosis is not really high on my differential, but maybe I'm missing something.)

We really need a much more solid picture of her. For all we know this isn't an acute onset, but something unmasked. C'mon psisci, we can't really evaluate someone with that limited amount of information. I would like all the basics : PMH (CV risk factors, previous infection), PSH (unlikely to be relevant, but who knows), Social Hx (who sees her, drug use/abuse, how she manages on her own), Family Med Hx(related conditions of any kind, any early onset dz's), ROS (I can't believe this is purely psychotic, she had to at least have had a HA, previous syncopal episodes, aphasias, etc.), full MSE, and repeated vitals at each interaction.
 
I would give it, if I had it. This is life in primary care. I see her weekly. Nobdy has mention the hypothalmus yet????
 
Any other ideas of what I should get q-visit besides vitals? I will do a baseline MSE (aside from my clincial interview) at next visit. I agree with Sazi too, and I wish I had more. FYI, this pt is being treated at a FP residency training program, and myself and a very good psychiatrist are consulting with the 2nd year resident who is a very good FP resident..compared to alot of the 25 y/o, nervous as hell kids who take up most of the 666 slots.
 
psisci said:
Any other ideas of what I should get q-visit besides vitals? I will do a baseline MSE (aside from my clincial interview) at next visit. I agree with Sazi too, and I wish I had more. FYI, this pt is being treated at a FP residency training program, and myself and a very good psychiatrist are consulting with the 2nd year resident who is a very good FP resident..compared to alot of the 25 y/o, nervous as hell kids who take up most of the 666 slots.
Click to expand...

How about a home visit, to look for evidence of alcoholism?
This isn't DTs, but could be a persisting substance-induced amnestic disorder (e.g. Wernicke's encephalopathy). I don't suppose we got a GGT on that HTN admission, did we?
 
I know you are not a doctor but how could a FP resident (medical doctor) and his attending not consider and do a LP promptly???? The case you presented isn't done int he traditional medical model withddx construction etc. We were given inadequate and poorly organized data. I agree with the "big dog" Nazi.
 
DeanWormer said:
I know you are not a doctor but how could a FP resident (medical doctor) and his attending not consider and do a LP promptly???? The case you presented isn't done int he traditional medical model withddx construction etc. We were given inadequate and poorly organized data. I agree with the "big dog" Nazi.
Click to expand...


I bet they had thought about it but she probably refused. At least that's what happened with a patient of mine in a similar situation.
 
Who might be the big dog Nazi??? I am sorry Dean that the info was presented to you like a textbook, but I presented what I had. In the real world you will often see this.
One of the many problems with this case is that nobody has found anything substantial. I chose to omit info to help protect this pts privacy, and if it was not helpful. The fact that this pt is just now getting a LP, new MRI etc tells you alot about what was not found on round 1.
I am thinking vascular dementia at his point.......
 
Everything has been normal except this patient tests positive for syphillis in the blood, but not in the CSF. MRI has improved slightly but still shows diffuse bright spots with T2, but MS was ruled out. The only outstanding test is for west-nile virus...the timing is right.
 
Sorry, VDRL. By the way she has had a + VDRL since 12 y/o. Mom is a nurse and from a small town where they screened everyone at the time. RPR is pending.
 
EEG was totally normal? no slowing? Just scalp electrodes or sphenoidals/nasopharyngeals too?

MRI with or without contrast? How about MRA? Any altered diffusion (esp. of hippocampi)?
 
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