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) 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. It is difficult to draw more defini- reports that he has 2 wives and the wife in the tive conclusions and Mr. E is discharged home Current Psychiatry 42 July 2012 room was not the real one, which suggests with minor improvement in his symptoms. He Cases That Test Your Skills

didn’t attend follow-up appointments. During a courtesy call a few months after his admis- Related Resources • Kaufman DM. Clinical neurology for psychiatrists. 6th ed. sion, his wife revealed that Mr. E had died after Philadelphia, PA: Saunders Elsevier; 2007. shooting himself. It is unclear if it was an ac- • Sidhu KS, Balon R, Ajluni V, et al. Standard EEG and the difficult- cident or suicide. to-assess mental status. Ann Clin Psychiatry. 2009;21(2):103-108. Drug Brand Names The authors’ observations Acyclovir • Zovirax Olanzapine • Zyprexa Ceftriaxone • Rocephin Quetiapine • Seroquel Mr. E’s diagnosis remains unclear (for a Ciprofloxacin• Cipro Thiamine • Betaxin summary of his clinical course, see Table Haloperidol • Haldol Vancomycin • Vancocin Lorazepam • Ativan 2). Although his initial presentation was consistent with delirium, the lack of an Disclosure The authors report no financial relationship with any company identifiable medical cause, prolonged time whose products are mentioned in this article or with manufactur- course, and lack of improvement with do- ers of competing products. Clinical Point pamine blocking agents suggest additional diagnoses such as Wernicke-Korsakoff Mr. E’s CT and MRI syndrome, rapidly progressive , scans, history of or a substance-induced disorder. He dis- tia, or another neurologic problem that we alcohol use, and played paranoia and bizarre , have not identified. Our tentative diag- cirrhosis point to which would suggest a . nosis was Wernicke-Korsakoff syndrome Wernicke-Korsakoff However, he also had a history of substance because of his history of alcohol use and syndrome as an use. A few months after we saw Mr. E, “bath imaging findings. salt” (methylenedioxypyrovalerone) abuse Although we used a multidisciplinary underlying diagnosis gained national attention. Patients with team approach that included psychiatry, bath salt intoxication present with confu- internal medicine, neurology, neuropsy- sion, paranoia, and behavioral disturbances chology, and an aggressive and thorough as well as a prolonged course.8 workup, we could not establish a defini- Mr. E’s CT and MRI scans, history of tive diagnosis. Unsolved cases such as this alcohol use, and cirrhosis also point to can leave patients and clinicians frustrated Wernicke-Korsakoff syndrome as an un- and may lead to unfavorable outcomes. derlying diagnosis. It is unclear whether Additional resources such as a telephone Mr. E experienced alcohol withdrawal and call after the first missed appointment may IV glucose without adequate thiamine re- have been warranted. placement during a prior surgery. However, MRI findings were unchanged from a pre- References 1. Jiang W, Gagliardi JP, Raj YP, et al. Acute psychotic disorder vious study 10 years ago. after gastric bypass surgery: differential diagnosis and It is puzzling whether Mr. E’s AMS was treatment. Am J Psychiatry. 2006;163(1):15-19. 2. Harrison RA, Vu T, Hunter AJ. Wernicke’s encephalopathy a first psychotic break, a result of drug and in a patient with . J Gen Intern Med. 2006; alcohol use, rapidly progressing demen- 21(12):C8-C11.

Bottom Line Paranoia and altered mental status (AMS) may be multifactorial. Teasing out an exact cause can be difficult and frustrating. Closely monitor patients who present with AMS for harm to themselves or others, even if their history doesn’t suggest Current Psychiatry suicidality or homicidality. Vol. 11, No. 7 43 continued Cases That Test Your Skills

3. Sechi GP, Serra A. Wernicke’s encephalopathy: new clinical 6. Sadock BJ, Sadock VA. Delirium, dementia, and amnestic settings and recent advances in diagnosis and treatment. and other cognitive disorders. In: Sadock BJ, Kaplan HI, Lancet Neurol. 2007;6(5):442-455. Sadock VA. Kaplan and Sadock’s synopsis of psychiatry: 4. American Psychiatric Association. Practice guidelines for behavioral sciences/clinical psychiatry. Philadelphia, PA: the treatment of patients with delirium. Am J Psychiatry. Lippincott Williams and Wilkins; 2007:319-372. 1999;156(5 suppl):1-20. 7. Ahmad SA, Archer HA, Rice CM, et al. Seronegative limbic 5. Sharon KI, Fearing MA, Marcantonio RA. Delirium. In: encephalitis: case report, literature review and proposed Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard’s treatment algorithm. Pract Neurol. 2011;11(6):355-361. geriatric medicine and gerontology. 6th ed. New York, NY: 8. Ross EA, Watson M, Goldberger B. “Bath salts” intoxication. McGraw-Hill Medical; 2009:647-658. N Engl J Med. 2011;365(10):967-968.

Clinical Point Although we used a multidisciplinary team approach, we could not establish a definitive diagnosis