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Who Let the Dogs Out? a Case of Delirium Induced by Lyme Borreliosis in a Patient With a Severe Intellectual Development Disorder
- Joana Marques Pinto, José Diogo Andrade, Joana Andrade, Vera Martins
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S122
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Aims
Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixode. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves regardless of antibiotic treatment. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases.
MethodsWe describe a case of a 47-year-old male, with severe intellectual development disorder (IDD), who presented with behavioural changes, aggressiveness, psychomotor agitation and confusion. 15 days prior to admission in the psychiatry ward he had recurred several times to the emergency department with similar clinical presentation, and had been discharged following adjustments to his medication. After showing no improvement and no response to treatment he was admitted. He then presented fever and laboratory study (LS) revealed increased inflammatory markers. His family also informed he came from a rural area and had contact with wild dogs. No tick bite or erythema was identified during physical examination. Nevertheless a serologic study for Borrelia burgdorferi was performed and turned out positive. An antibiotic regimen was administered and and the patient's symptoms fully remitted 48 hours after treatment was initiated.
ResultsBorreliosis usually presents erythema at the site of the tick bite which could have already resolved when the patient was examined. It was first assumed that the clinical manifestations were part of his psychiatric condition. An infectious etiology was presumed after the onset of fever and increased inflammatory markers were identified. Given the patient's context, Borrelia in particular was considered a likely hypothesis. This case illustrates the difficulties of differential diagnosis inherent to patients with IDD, both because of the pathology itself, which can mask such clinical manifestations as delirium, and of the stigma associated with mental health patients, which frequently cuts the diagnostic work-up of organic causes short.
ConclusionThis case highlights the clinical challenge patients with IDD represent. Differential diagnosis can be elusive, especially in the context of infectious diseases like borrelia, as they can present with unspecific clinical manifestations in this subgroup of patients, and hence why a complete and thorough clinical evaluation is essential. This case also illustrates that mental health patients suffer from stigma: Being branded a “psychiatric patient” created a 16-day delay between onset of symptoms and appropriate treatment initiation- antibiotics.
Mania With Psychotic Symptoms a Rare Clinical Presentation of Fahr's Disease- a Case Report
- Joana Marques Pinto, José Diogo Andrade, Joana Andrade, Vera Martins
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S121-S122
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Aims
Fahr's disease is a rare neurodegenerative disease with radiological findings of symmetrical and bilateral idiopathic calcifications of the cerebellum, periventricular white matter, and basal ganglia, characterized by the presence of neuropsychiatric symptoms.
MethodsWe report a case of a 46-year-old male who presented with psychomotor agitation, aggression, restlessness, irritability, decrease need for sleep and psychotic symptoms including grandeur and mystical delusions. He had a previous history of an admission 4 years prior with a similar presentation. Computed tomographic scan of the patient demonstrated a bilateral calcification of globus pallidus. Laboratory investigation was unremarkable. Due to agitation, the patient started treatment with Haloperidol 10 mg and Levomepromazine 25 mg presenting resulting in important extra-pyramidal symptoms (EPS), namely marked motor rigidity. Subsequently, a switch was made to Olanzapine 5 mg with persistence of clinically significant EPS. A final switch was made to Aripiprazol 15 mg (gradually titrated) and a mood stabilizer was started (Sodium Valproate), with full clinical remission within a month and no signs of EPS.
ResultsThe age of onset of manic symptoms in this patient is not suggestive of bipolar disorder (average age onset 25). On the other hand, Fahr's disease usually presents within the 4th and 5th decade of life. The clinical presentation usually involves motor symptoms (movement disorder and Parkinson like symptoms) and dementia, but purely psychiatric presentations have been described. The localization of calcifications also seems to have a clinical correlation, as Pallidal calcifications as the ones identified in our patient have been associated with manic symptoms. Idiopathic forms in which no metabolic or other underlying causes are identified, treatment is usually symptomatic, but one has to be cautious because these patients have an increased sensitivity to neuroleptics and can thus easily develop EPS.
ConclusionPsychiatrists should consider Fahr's disease as a differential diagnosis in a manic episode, especially with a late age of onset, which is not suggestive of a bipolar disorder. This case also further emphasizes the importance of neuro-imaging in psychiatry and underlines the importance of a careful treatment approach in this type of patients because of an higher risk of developing EPS.