Transcript Neurosyphilis Psychiatric Manifestations

Neurosyphilis
Psychiatric Manifestations
HPI
62yo AAM
5 to 6 months
“making funny sounds with mouth, as if smacking when eating”,
w/ patient unaware of behavior
2 months
bilateral upper extremity tremor
Referral to Caddo Health Unit 3/17/05 w/ +RPR @ 1:16 dilutionsbenzathine penicillin @ 2.4 million units IM 4/5/05 and 4/12/05
1 month
progressive deterioration of speech
confusion w/ obvious cognitive decline
bizarre behavior (disconnecting appliances, moving furniture)
paranoid ideations, w/ delusions of jealousy
A/VH
headaches, decreased vision OS
Neurosyphilis
Psychiatric Manifestations
PPH
None
PSH
Prostate hypertrophy, w/ TURP (9/03)
Repair of incarcerated right inguinal hernia (4/05)
PMH
Hypertension
Neurosyphilis
Psychiatric Manifestations
FH- Alzeimer’s dementia (mother)?
SH- Born in Gloster, LA by unremarkable home delivery
3rd of 7 children, w/ no reported developmental issues
Parents described as “the best people I had”
12th grade education (“a good basketball player”, + contact w/ teachers)
Work x 39y as truck driver (“18 wheeler”); current $ from SS + wife’s job
Lives w/ common law wife of 29y (24yo daughter + 2 other adult children)
Rare church attendance, no military, no legal issues/incarceration
Tobacco @ 50 PY (abstinence beginning w/ current illness)
No ETOH or illicit substances
Neurosyphilis
Psychiatric Manifestations
ROS
Upper extremity tremor
Recurrent headaches
Decreased visual acuity, OS
PE
BP=162/93, P=112, T=98.8
NeurologicalSlightly agitated, w/ resting (“adrenergic”) tremor
Alert but disoriented, dysarthric
Cranial nerves 2 to 12 intact, w/ unremarkable pupils and fundi
Motor/sensory intact, w/ normal DTR’s and no abnormal reflexes
No ataxia, w/ “steady” gait; negative Romberg
Neurosyphilis
Psychiatric Manifestations
MSE (admission)
Casual attire, w/ some neglect in grooming, tatoo on left arm
Chronic resting tremor, facial “twitch”
Cooperative, but decreased eye contact
Incoherent speech (slurred and broken)
Appearance of depression, w/ “constricted” emotional expression
No appearance of response to internal stimuli
Unable to assess thought processes, but appearing confused
No suggestion of violent ideations
Alert, but disoriented as to year
Decreased attention/concentration
Decreased early recall
Limited insight/judgement (unable to identify reason for hospitalization)
MMSE=18/30 (4/18/05)
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Laboratory: CBC wnl (wbc=8.08)
CMP wnl, except glucose=118
U/A wnl
UDS negative, ETOH<10
ESR=25
Folate/B12 levels wnl
TSH wnl
HIV negative
RPR reactive
FTA-ABS reactive
MHA-TP reactive
Brain CT-normal study
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Neurology Consultation:
EEG-negative for seizure activity
MRI-bilateral frontal and basal ganglia changes,
consistant w/ encephalomyelitis (viral vs metabolic)
LP-clear/colorless CSF
OP=18 cm of water
wbc=0, rbc=117
glucose=60, protein=37
stains/cultures negative for fungus, AFB, bacteria
Cryptococcus Ag latex negative
VDRL reactive at 4 dilutions
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Infectious Disease Consultation:
Encephalitis panel (r/o viral etiology)
+ Ab
HSV, CMV, measles
- Ab
Eastern and western equine, California, Saint Louis,
LCM, adenovirus, influenza, Varicella zoster,
cocksackie, echovirus, mumps
Penicillin G IV @ 4 million units q4h x 14 days
Benzathine penicillin @ 2.4 million units IM q week x 3 doses
F/U w/ RPR and VDRL at 3, 6, and 12 months
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Opthamology consultation:
Choreoretinitis OS, consistent w/ neurosyphilis
F/U at 6 months, after completion of antibiotic regime
Audiology testing:
Bilateral sensorineural hearing loss
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Neuropsychiatric Testing:
Lezak Memorization of 16 Items
“Statistically deviant”
Dementia Rating Scale
“Severely impaired”
Weschler Abbreviated Scale of Intelligence
IQ (full scale)=61
Wide Range Achievement Test
Reading/spelling within “severe learning d/o” classification;
arithmetic at “low average”
Thermatic Apperception Test
Data suggestive of “…proneness to withdraw from social conflict”
Impression-Dementia due to medical condition
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Psychopharmacologic Management:
4/18/05-Lorazepam 1 mg PO q12h prn agitation/aggressive behavior
4/21/05-Risperidone 1 mg PO bid
Trazodone 50 mg PO HS
Lorazepam 2 mg IM
4/24/05-Haloperidol 5 mg/Lorazepam 2 mg/Diphendramine 50 mg IM
5/2/05-Risperidone 1 mg PO HS
5/4/05-Haloperidol 5 mg/Lorazepam 2 mg/Diphendramine 25 mg IM
Neurosyphilis
Psychiatric Manifestations
Hospital Course
MSE (discharge, 5/12/05)
Groomed
Behavior appropriate
Speech coherent, although slow and soft
Euthymic, affect congruent
Some paranoia; no evidence of A/VH
Alert, oriented to self and time
Reduced memory
Limited insight/judgment
Neurological exam (discharge)
Normal
Neurosyphilis
Psychiatric Manifestations
Hospital Course
Discharge (5/12/05)
Medications
Risperdal 1 mg HS
ASA 81 mg/d
F/U
Psychiatry Clinic, 6/9/05
Opthamology Clinic, 10/05
STD Clinic, 5/19/05
CCC, prn
Neurosyphilis
Psychiatric Manifestations
Clinic F/U
MSE (2/16/06)
Casual, groomed/clean
Cooperative, w/ good eye contact
Limited perioral movement (rated at level 1 on AIMS)
Paucity of speech, yet coherent; minor stuttering/hesitation (lifetime history)
Language:
+Object naming, repeating (“no ifs, ands, or buts”)
+Following 3-stage command, reading and obeying, design copying
-Unable to write a sentence
Mood “all right”, blunted affect
Perception clear w/o apparent A/VH or paranoia
Thought clear, organized and goal-directed w/o violent ideations
Alert and oriented to all parameters
Registration=3/3, recall at 3 to 5 minutes=2/3
100-7=93-7=?(25-5=20-5=15, 2+2=4+4=8+8=16); unable to spell “ WORLD” backwards
“Don’t cry over spilled milk”~”Don’t interfere in anything.”
Insight and judgment fair
Neurosyphilis
Psychiatric Manifestations
Clinic F/U
MMSE
4/18/05-19/30
1/10/06-21/30
2/07/06-23/30
Medications
Risperidone 1 mg HS
Namenda 10 mg/d (begun 10/19/05)
Clonidine 0.1 mg bid
Neurosyphilis
Psychiatric Manifestations
Named for the mythical swineherd Syphilis,
accursed with the disease by Apollo
First described in a Latin poem written by an Italian physician
Rampaged across Europe in the 1400’s,
soon becoming endemic to much of the world
True origin a mystery,
possibly returned to Europe from native North Americans
Became known as the French disease, and “the great imitator”
Hutto B. Syphilis in clinical psychiatry: A review.
Psychosomatics 2001;42:453.
Neurosyphilis
Psychiatric Manifestations
Kraft-Ebbing demonstrated association to general paresis in 1897
Prior to 1945, general paresis reportedly involved in 5% to 10%
of all first psychiatric admissions
Scheck DN, Hook E III: Neurosyphilis.
Infect Dis Clin North Am 1994;8:769.
In 1920s, >20% of patients in US mental hospitals with tertiary syphilis
Brandt AM: No Magic Bullet:
A social History of Venereal Disease in the United States Since 1980.
New York, Oxford University Press, 1987.
In 1997, overall rates of syphilis decreased to lowest levels ever
and US Public Health Service targeted disease for elimination
St Louis ME, Wasserheit JN.
Elimination of syphilis in the United States.
Science 1998;281:353.
Neurosyphilis
Psychiatric Manifestations
Included in psychiatric differential diagnosis for:
Dementia
Psychosis
Mood disorders
Incidence presenting initially with psychiatric symptomatology unclear
Classic syndromes such as tabes dorsalis now less common than
asymptomatic presentation versus manifestations such as
seizures or ocular and auditory involvement
Scheck DN, Hook E III: Neurosyphilis.
Infect Dis Clin North Am 1994;8:769.
Neurosyphilis
Psychiatric Manifestations
Objectives:
1. Review the pathophysiology of neurosyphilis,
emphasizing psychiatric manifestations;
2. Raise awareness of the importance of routine screening for
latent syphilis in psychiatric patients, particularly those
presenting with psychosis and mood disorders as well as
dementia;
3. Encourage aggressive pharmacologic management of both
the medical and psychiatric components of the illness, with
realistic expectations of favorable results.