A Perplexing Case of Altered Mental Status Ravi Shankar, MD, and Derek Mongold, MD

Cases That Test Your Skills A perplexing case of altered mental status Ravi Shankar, MD, and Derek Mongold, MD How would you Mr. E, age 55, has a 2-week history of altered mental status, sleep handle this case? disturbance, and decreased appetite and speech. Medical workup Visit CurrentPsychiatry.com to input your answers does not reveal an underlying cause. How would you proceed? and see how your colleagues responded CASE Agitated and paranoid tized on a helicopter to find out what is wrong Mr. E, age 55, presents to the emergency de- with me.” His wife states that Mr. E drank vodka partment (ED) with a 2-week history of altered daily but decreased his alcohol consumption mental status (AMS). His wife reports, “He was after surgery 5 months ago. Before his current normal one day and the next day he was not.” admission, he was drinking approximately Mr. E also presents with sleep disturbance, half a glass of vodka every few days, accord- decreased appetite and speech, and a 20-lb ing to his wife. Mr. E says he has no prior psy- weight loss. His family reports no recent stress- chiatric admissions. During the mental status ors or head trauma. Mr. E is agitated in the ED exam, his eye contact is poor, with latency of and receives a single dose of IV haloperidol, 5 response to questions, thought blocking, and mg. He exhibits paranoia and is afraid to get a psychomotor retardation. He is alert, oriented CT scan. The medical team attempts a lumbar to time, place, and person, and cooperative. puncture (LP), but Mr. E does not cooperate. He cannot concentrate or focus during the His laboratory values are: potassium, 3.0 interview. He denies suicidal or homicidal mEq/L; creatinine, 1.60 mg/dL; calcium, 10.6 ideation. mg/dL; thyroid-stimulating hormone, 0.177 IU/L; vitamin B12, >1500 pg/mL; folate, >20 What would be your working diagnosis? ng/mL; and creatine kinase, 281 U/L. Urine a) delirium not otherwise specified (NOS) drug screen is positive for benzodiazepines b) psychosis NOS and opiates, neither of which was prescribed, c) delusional disorder and blood alcohol is negative. d) substance-induced mood disorder Mr. E is admitted for further workup of AMS. e) Wernicke-Korsakoff syndrome His daughter-in-law states that Mr. E is an alco- holic and she is concerned that he may have The authors’ observations mixed drugs and alcohol. The medical service Mr. E appeared to be delirious, as evi- starts Mr. E on empiric antimicrobials—van- denced by the sudden onset of waxing and comycin, ceftriaxone, and acyclovir—because waning changes in consciousness, atten- of his AMS, and performs an LP to rule out tion deficits, and cognition. He also had a intracranial pathology. His LP results are history of daily alcohol use and decreased unremarkable. Mr. E appears to be confused during psy- Dr. Shankar is a Fellow in Child and Adolescent Psychiatry and Current Psychiatry Dr. Mongold is Assistant Professor, Department of Behavioral 40 July 2012 chiatric evaluation. He requests to be “hypno- Medicine, West Virginia University, Morgantown, WV. Cases That Test Your Skills his alcohol intake after a surgery 5 months Table 1 ago, which puts him at risk for Wernicke’s encephalopathy.1-3 The type of surgery and Suggested workup for altered whether he received adequate thiamine mental status supplementation at that time was unclear. Complete blood count, basic metabolic profile, Because Mr. E is older, he has a higher risk creatine kinase of mortality and morbidity from deliri- Thyroid-stimulating hormone, thyroid scan um.4,5 We started Mr. E on quetiapine, 50 Vitamin B12, folate, thiamine mg/d, for delirium and an IV lorazepam Blood alcohol, urine drug screen taper, starting at 2 mg every 8 hours, be- Urine analysis and cultures cause the extent of his alcohol and benzo- Lumbar puncture—CSF staining and cultures diazepine use was unclear—we weren’t Chest radiography sure how forthcoming he was about his CT and MRI scan of brain Clinical Point alcohol use. He received IV thiamine sup- Electroencephalography Mr. E has a history of plementation followed by oral thiamine, Neuropsychiatric testing 100 mg/d. CSF: cerebrospinal fluid alcohol use and he Source: Reference 6 decreased his alcohol Which test(s) would you order? intake 5 months ago, a) electroencephalography (EEG) which puts him at b) MRI normal heavy metals, ammonia, cerulo- risk for Wernicke’s c) cerebrospinal fluid (CSF) workup plasmin, and thiamine. We suspected lim- d) all of the above bic encephalitis because of Mr. E’s memory encephalopathy problems and behavioral and psychiatric The authors’ recommendations manifestations,7 but CSF was unremark- We requested a neurology consult, EEG, able and limbic encephalitis workup of CSF cultures, and brain MRI (Table 1).6 CSF and paraneoplastic antibody panel EEG, chest radiography, thyroid scan, and were negative. CT scan were normal and MRI showed Mr. E’s primary care physician stated no acute intracranial process. However, that at an appointment 1 month ago, Mr. there was a redemonstration of increased E was alert, oriented, and conversational T1 signal seen within the bilateral basal with normal thought processing. At that ganglia and relative diminutive appear- time he had presented with rectal bleed- ance to the bilateral mamillary bodies, ing, occult blood in his stool, and an unin- which suggests possible liver disease and/ tentional 25-lb weight loss over 2 months. or alcohol abuse. These findings were un- It was not clear if his weight loss was changed from an MRI Mr. E received 10 caused by poor nutrition—which is com- years ago, were consistent with his history mon among chronic alcoholics—or an oc- of alcohol abuse, and may indicate an un- cult disease process. derlying predisposition to delirium. A CT After 10 days, Mr. E was discharged scan of the abdomen showed hepatic cir- home from the medicine service with no rhosis with prominent, tortuous vessels clear cause of his AMS. Discuss this article at of the upper abdomen, subtle ill-defined www.facebook.com/ hypodensity of the anterior aspect of the CurrentPsychiatry liver, and an enlarged spleen. EVALUATION Worsening behavior Mr. E’s mental functioning did not im- One week later, Mr. E presents to the ED with prove with quetiapine and lorazepam. continued AMS and worsening behavior at Further evaluation revealed a negative home. Two days ago, he attempted to strangle Current Psychiatry human immunodeficiency virus test and his dog and cut himself with a knife. His para- Vol. 11, No. 7 41 Cases That Test Your Skills Table 2 Mr. E’s clinical course Symptoms Treatment First Agitation Empiric antimicrobials for possible ED visit Confusion meningitis Sleep disturbance Haloperidol for agitation Decreased appetite and speech Quetiapine for delirium 20-lb weight loss Lorazepam taper Thiamine supplementation Second Violent behavior Switch from ceftriaxone to ciprofloxacin ED visit Worsening paranoia for Pseudomonas aeruginosa Responding to internal stimuli Switch from quetiapine to olanzapine Clinical Point Mr. E believes he has 2 wives, but the wife in the room is not the real one, which We suspected suggests possible Capgras syndrome limbic encephalitis Cognitive deficits on mental status exam because of Mr. E’s ED: emergency department memory problems and psychiatric noia was worsening and his oral intake contin- Capgras syndrome. His wife provides a home manifestations, but ued to decrease. In the ED, Mr. E does not want medication list that includes vitamin B com- CSF was unremarkable a chest radiograph because, “I don’t like radia- plex, vitamins B12, E, and C, a multivitamin, tion contaminating my body”; his family stat- zinc, magnesium, fish oil, garlic, calcium, glu- ed that he had been suspicious of radiography cosamine, chondroitin, herbal supplements, all of his life. He receives empiric ceftriaxone and gingko. The psychiatry team recommends because of a possible urinary tract infection. switching from quetiapine to olanzapine, Urine culture is positive for Pseudomonas ae- 15 mg/d, because Mr. E was paranoid about ruginosa and he is switched to ciprofloxacin. taking quetiapine. Mr. E is admitted for further workup. We determine that Mr. E does not have Mr. E’s mother states, “I think this change medical decision-making capacity. in behavior is related to my son drinking alco- Because his symptoms do not improve, hol for 20 years. This is exactly how he acted Mr. E is transferred to the psychiatric inten- when he was on drugs. I think he is having a sive care unit. His mental status shows little flashback.” She also reports her son purchased change while there. Neuropsychiatric test- multiple chemicals—the details of which are ing shows only “cognitive deficits.” He shows unclear—that he left lying around the house. signs consistent with neurologic dysfunc- His wife says that after discharge a week tion in terms of stimulus-bound respond- ago, Mr. E was stable for 1 or 2 days and then ing and perseveration, which is compatible “he started going downhill.” He became more with the bilateral basal ganglia lesion seen paranoid and he started talking about cameras on MRI. However, some of his behaviors sug- watching him in his house. Mr. E took quetia- gest psychiatric and motivationally driven or pine, 50 mg/d, for a few days, then refused be- manipulative etiology. During this testing he cause he thought there was something in the was difficult to evaluate and needed to be medication. Mr. E’s family feels that at times convinced to engage. At times he was illogi- he is responding to internal stimuli. He makes cal and at other times he showed good focus statements about his DNA being changed and and recall.

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