Psychosis + head titubations and upper extremity tremors

[Psychferlyfe3000]

Almighty SDN brain trust, I have brought you another offering--one which is befuddling my team. Any help is appreciated for the sake of this patient.

We have an early-20s woman on our inpatient unit who was high functioning and then had a first-break psychosis 2 months ago. She was given fluphenazine LAI + PO fluphenazine in late March at an outside hospital and supposedly improved and was discharged home. At home, she was found to be overly sedated and the PO fluphenazine was peeled off. She refused her next LAI. She was then started on quetiapine 300mg by an outside provider. She presented to us in late April with delusional thinking relating to various folks in her life. She had a flat affect and was hypokinetic but then would have bouts of moderate to severe agitation. We thought perhaps she had hyperactive catatonia. However, here's the odd thing: She has head and truncal titubations and a bilateral upper extremity tremor. It is severe enough that she can barely put food into her mouth. Psychologically, she is mostly linear now, but the physical symptoms continue. Does anyone have any thoughts as to what might be going on with her? Presumably the fluphenazine LAI has worn off by now.

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[Celexa]

Well... She needs a medical workup.

 

[Bartelby]

I agree with the above. I would consult neuro to evaluate further. It could be something like autoimmune cerebellitis (https://n.neurology.org/content/90/16/746).

 

[splik]

I automatically go to hysteria for everything these days because I see so much of it but I actually have a pt with paraneoplastic cerebellitis who had head titubations, emotional dysregulation, tremors, and psychosis. Cancer dx became apparent 2 yrs after onset of symptoms. Differential also includes Wilson's disease, inborn errors of metabolism (e.g. metachromatic leukodystrophy), heavy metal toxicity, MS, autoimmune, infectious etc. Pt need MRI under sedation at very least. It could be related to the fluphenzaine - can persist even after cessation.

 

[Psychferlyfe3000]

I automatically go to hysteria for everything these days because I see so much of it but I actually have a pt with paraneoplastic cerebellitis who had head titubations, emotional dysregulation, tremors, and psychosis. Cancer dx became apparent 2 yrs after onset of symptoms. Differential also includes Wilson's disease, inborn errors of metabolism (e.g. metachromatic leukodystrophy), heavy metal toxicity, MS, autoimmune, infectious etc. Pt need MRI under sedation at very least. It could be related to the fluphenzaine - can persist even after cessation.

Okay, very interesting that two folks brought up paraneoplastic cerebellitis. That is also something I had stumbled upon in my search. That really does fit the picture in several ways. The persistence of side effects from fluphenazine has been my primary diagnosis. Presumably fluphenazine levels are not useful at this point, right? Am I correct in assuming that acute EPS after short-term AP use can persist even without detectable antipsychotic levels? Also, what are your thoughts on investigating CYP variants? Useful in this scenario or no?

 

[Stagg737]

Agree with medical work up. We also need a better timeline of meds and symptoms to be more helpful.

What re-stabilized her psychotic symptoms and what is she taking now? When did the titubations and abnormal movements start? How stable was “stable” before she came back? Why did she refuse the LAI?

 

[Celexa]

I was rather brief and glib before because I was on a bus, but to be more detailed, I agree with everyone above. Patient needs a genuinely medical workup. This is someone I would be fighting to get her an LP. She definitely needs an MRI and neurology input. Body imaging too, to look for a tumor (ovarian teratoma being the one most commonly associated with paraneoplastic syndromes in young women). Needs the basic labs as well as screening for Wilson's etc. This is not someone who should stay on inpatient psych not making progress. There's some real bad (yet treatable, if caught) things that need to be looked for.

 

[calvnandhobbs68]

Yeah this is a neuro consult, hopefully LP from neuro and MRI at a minimum. Splik gave a pretty decent differential above but basically anyone with sudden new onset psychosis and neuro findings of any sort needs more of a medical workup before starting to attribute this to med side effects, especially since med was discontinued so this should have improved if related.

 

[Crayola227]

This case is basically exactly why psychiatrists or anyone treating psych disorders needs to be a full-fledged physician, with all of that medical training. It's not a job for someone with less education and a prescription pad.

 

[docksan]

Any time I see a new onset psychosis or one that obviously isn't malingering but has no evidence of a workup that can rule out something that explains it better I do a work up.

Too many times I've seen already patients seen by a mid level or who were admitted immediately and then your workup reveals no primary psych to rule in. It's annoying and hurts the patient.

 

[deleted1100659]

agreed, first episode psychosis generally always needs a medical workup and a proper examination. Bilateral tremor in the upper extremities. Worsens with movement or improved? What kind of tremor is it? Whats her gait? Focal neurological deficits? How rapid was the decline? Clean UDS? No evidence of infection? I would be getting a RPR (I have seen neurosyphillis 3x), ESR, UDS, CRP, CMP, UA, CBC w/ diff, ammonia, TSH/Free T4, +/- imaging if labs revealed nothing else and the presentation was rapid onset, +/- LP depending on what the labs showed.

 

[Psychferlyfe3000]

agreed, first episode psychosis generally always needs a medical workup and a proper examination. Bilateral tremor in the upper extremities. Worsens with movement or improved? What kind of tremor is it? Whats her gait? Focal neurological deficits? How rapid was the decline? Clean UDS? No evidence of infection? I would be getting a RPR (I have seen neurosyphillis 3x), ESR, UDS, CRP, CMP, UA, CBC w/ diff, ammonia, TSH/Free T4, +/- imaging if labs revealed nothing else and the presentation was rapid onset, +/- LP depending on what the labs showed.

Tremor worsens with movement. Gait is normal. Rapidity of decline is not clear but over a matter of weeks. UDS is clean. They have leukocytosis ~ 15 as it turns out. Otherwise, the labs you bring up are (-). No LP.

 

[deleted1100659]

Tremor worsens with movement. Gait is normal. Rapidity of decline is not clear but over a matter of weeks. UDS is clean. They have leukocytosis ~ 15 as it turns out. Otherwise, the labs you bring up are (-). No LP.

Has she had the tremor before or this completely new? Essential tremors can be bilateral and affect the head but if this randomly appeared in the span of a few weeks, that would be odd.

Another thing would be to observe her when she isnt aware, curious if tremors could be psychosomatic as well (not impossible).

Out of curiosity I wonder if a beta blocker would improve the tremor sx with her