JOINT NEUROPSYCH CONFERENCE

BLOCK 5B

The patient is LM, a 31/M, a heavy alcoholic drinker, but otherwise a previously healthy individual with no known comorbidities.

Typhoon Ondoy occurred and flooded the streets a week prior to admission.

3 days PTA, • Patient had history of undocumented fever,

dyspnea, weakness, pain on the lower back, chest, RUQ, right flank and lower extremity, loose yellowish stool 4x a day, cough and colds with whitish sputum, oliguria, tea colored-urine and vomiting. (+) History of wading in the flood. Patient self-medicated with paracetamol with no relief of symptoms.

Days prior to admission, • The patient did not have any change in

behavior or consciousness. He also reported to be constantly intoxicated on previous days, before or even after the typhoon

On the day of admission:• Patient was seen at the ER and found to

have persistence of symptoms, with BP of 90/60, heart rate of 112, respiratory rate of 22 and afebrile.

HISTORY 1st MICU Day (Thursday)

◦ On interview, the patient was agitated and kept on calling names of people he knows, but are not present in the room

◦ He kept on saying “kamukha ni…” or “hawig ni…”◦ He was very agitated, and had a short attention

span as he kept on reiterating that he wanted to go to the bathroom, even when he was reminded constantly that he already had a catheter

HISTORYUnderwent dialysis– During neck and femoral fistula placement, when asked

by the fellow if he was in pain, he would just shrug his head and appeared passive to any sensation of pain

– (+) hypotensive episodes (80/50) while on dialysis, dopamine drip increased

– (+) waxing and waning of consciousness• He would ask about his blood pressure, and he would ask if

the IVF were running– (+) regard, but started talking gibberish with right

intonation --> Felt frustrated when he was not understood, sighed and looked exasperated

– After 30 minutes, he was comprehensible again, and recognized his father, repeated his need to urinate

• Would become irritable at times, complaining to his watchers about his clothes– “yung shorts ko” which he was wearing prior to the

dialysis, and insisted on wearing them in spite that the nurse already told him to wait for awhile because the fistula was going to be cleaned and bandaged

– Remembered his “missing” shirt, and said that it was ok if it was lost because it was already old, but the patient came to dialysis already shirtless

• Pt was also seen talking/mumbling to himself loudly and saying incoherent phrases like “may buhangin ka sa mukha”

• Pt is sometimes awake, and would tug at his IV lines, and attempt to start conversations with those passing by

• Pt has also some lucid moments and was inquisitive–Would ask those who would monitor when they

went home, where they lived

• 2nd MICU day (Friday)– Patient wanted to drink water, and his father assisted

him. After taking a sip, he turned the bottle over the side and spilled all the water on the floor. During this time he recognized his father

– Patient would try to attract the attention of passers-by, “psst…psst” even if he doesn’t know them

– At times, he himself would cooperate and raise his arm when the monitoring team would come

– He would sometimes reach through air, as if grabbing some objects, and picking at imaginary things

3rd MICU day (Saturday)◦ Patient was noted to be tachycardic, febrile,

nauseated, with myoclonic seizures, and tremors◦ Patient started to sing loudly◦ He said “mayroon akong pusa sa dibdib” and he

would place his hands over his chest in an attempt to remove it

◦ Patient asked “nasaang beer house ako?”

4th MICU Day◦ The following morning, the patient was observed

to be more subdued, and not as loud as the previous days.

◦ CODE

Past Medical History: unremarkable

Past Family Medical History:◦ (+) heart disease and hypertension, father◦ (+) occasional alcoholic beverage drinkers

Past Psychiatric History◦ unremarkable

Personal and Social Profile◦ The patient finished High school◦ Currently works as a pedicab driver◦ (+) smoking, 5 pack years◦ (+) heavy alcoholic drinker, drinks everyday until

he passes out

ANAMNESIS Prenatal & Perinatal

◦ Pt was born via SVD to a then G5P4 mother, with no reported FMC. He was a product of a wanted pregnancy and is the youngest of 5 siblings

Early Childhood◦ Pt was breastfed for three months and then was shifted to bottle

feeding. Father reports that pt was at par with children of his age. No developmental delays were noted. As a young boy, he was fond of playing with his siblings.

Middle Childhood◦ Pt started schooling at age 6. He was an average student until

elementary. He had to stop studying when he was in grade 5 due to financial constraints. He then had to help with his mother and siblings sell fruits to provide added income to the family. He was always picked upon by his siblings during this time and would come to his mother for comfort. He had some friends and wasn’t able to play because he had to help earn income.

Late Childhood◦ Pt started to have a barkada whom he would always spend

time with. This was when he started to have habits of drinking and smoking. He started to become aloof from his siblings. He confided his family problems with his friends.

Adulthood ◦ His drinking habits persisted and even worsened getting

him mostly into trouble with the other drunkards of the neighborhood. He tried to do different jobs to earn a living, but he had the most success as a pedicab driver. He had several relationships with women but was not able to keep them due to his drinking problem. He still lived with his parents.

General Survey: • Awake, conscious, conversant, weak-looking, not

in respiratory distress.

Vital Signs: • BP 90/60• HR 104• RR 22• Temp Afebrile

PHYSICAL EXAMINATION

HEENT:• Pink conjunctivae, icteric sclerae, pupils EBRTL, (+)

subcojunctival suffusion, (-)NVE, (-) CLAD, (+) sunken eyeballs, dry lips and buccal mucosa

Chest/Lungs:• ECE, CBS, (-) alar flaring, (-) use of accessory muscles on

respiration, (-) wheezes, (-) cracklesCVS: • DHS, AP, tachycardic, regular rhythm (-) heaves, (-) thrills, (-)

adventitious heart soundsAbdomen: • Soft, non-tender, NABS, (+) abdominal pain on direct

palpation on RUQ, (+) CVA tenderness right sideSkin/Extremities: • Pink nail beds, full and equal pulses, (-) cyanosis, (-) edema, (+)

calf pain, (-) bleeding, (+) jaundice

PHYSICAL EXAMINATION

MSE• General Description: Patient has unkempt hair, and

long and dirty nails, shirtless, with soiled maong shorts and was seen lying on his bed. He had no distracting mannerisms, gestures, and pschymotor activity. However, he appeared agitated and would occasionally scan his environment. He has good eye contact, with ability to follow commands and requests and cooperative . Patient has episodes of talking gibberish, but with inflections and change in tone. But he still could talk spontaneously, in a normal rate, and normal tone, with clear and at appropriately placed inflections. Patient is cooperative.

MSEFunctional assessment : Patient could still

feed himselfMood, feeling, and affect: patient was noted

to have an over all blunted affect and constricted response, or a limited range of emotions

He answers in a logical,cohesive manner when asked, and gives relevant answers.

MSE Perceptual Disturbance: There were

preoccupations with his need to urinate and clothes. Aside from his confusion in identifying other people and calling out to them, there were hallucinations of seeing sand on faces, delusions of being inside a beer house. There were no suicidal and violent tendencies towards others and unusual dreams and fantasies expressed.

MSE• General Description: Patient has unkempt hair, and long

and dirty nails, shirtless, with soiled maong shorts and was seen lying on his bed.

• He was cooperative to the examiner and those who were monitoring.

• The patient‘s speech was normally responsive to cues from the interviewer, he has normal quantity, and rate of production. However, he would occasionally utter gibberish.

• He had no distracting mannerisms, gestures, and psychomotor activity. However, he appeared agitated and would occasionally scan his environment. He has good eye contact.

When the patient is asked, “kamusta ka na kuya?”, the patient answered: Ok lang.

The patient was irritable, and anxious.

MSE Perceptual Disturbance: Aside from his

confusion in identifying other people and calling out to them, there were hallucinations of seeing sand on faces, delusions of being inside a beer house.

Thought Content and Process◦ There were preoccupations with his need to

urinate and clothes.◦ There were no tangentiality, circumstantiality,

rambling, or evasiveness.◦ There were no suicidal and violent tendencies

towards others and unusual dreams and fantasies expressed.

The patient is alert, but only oriented to self, has poor concentration, poor memory and poor fund of knowledge

Poor insight to illness ◦ When asked why the patient was in the hospital:

“Nagtatae kasi ako”

BT : O+

CBC• 10/15 WBC 18.04 RBC 4.54

Hgb 140 Hct 0.374 MCV 82.4 MCH 30.8 MCHC 374 RDW 12.9 Plt 48 N 0.890 L 0.048

 Electrolytes• 10/16 crea 136 K 2.2• 10/15 HCV neg HbsAg neg

BUN 13.07 (high) Crea 236 (high) AST 154 (high) ALT 75 (high) Na 126 (low) K 1.8 (low)

 

ABG• 10/15 FiO2 21% Hgb 100 Tem 37 pH

7.394 pCO2 37.8 pO2 49.5 HCO3 23 TCO2 24.2 BE -1 O2 Sat 84.3%

 Urinalysis • 10/15 dark

yellow/hazy/1.015/5.5/CHO neg/CHON 1+/RBC 10-12/WBC 0-4/Cast waxy 0-1/EC neg/Bac 1+/MT rare/Crystals Bilirubin rare/Bil 2+/Urobil normal/Ketone trace/Leuco neg/Nitrite neg/Hgb 3+

12L ECG• 10/15 Sinus Tachycardia, Normal

axis, NSSTTWCs

Laboratory Results

What does our patient have?Leptospirosis in Weil’s Syndrome

High index of suspicion; wading in flood waters, myalgia + altered consciousness + fever

leptoMAT no results obtained

Metabolic encephalopathy

Multiple electrolyte abnormalities, altered sensoriumNo focal findings presentChronic alcohol use

Can not be ruled out

Alcohol Withdrawal More than 8 hours after cessation of drinking; perceptual disturbances + altered sensorium + sweating + tachycardia; history of heavy alcoholic drinking

Can not be ruled out

What other things will we consider in our patient?Substance Abuse Perspiration +

confusion + tachycardia, poor reliability of patient during history taking

Needs further investigation

Alcoholic Liver Disease

Elevated liver enzymes, jaundice, (+) right abdominal quadrant pain, intermittent fever, altered sensorium, alcoholic consumption

Additional tests needed to confirm the diagnosis

CNS infections(Typhoid Encephalitis)

Altered sensorium, intermittent fever, (+) headache

Obtain spinal fluid for culture and further investigation

MULTIAXIAL DIAGNOSISAXIS I Delirium due to multiple etiologies

Alcoholic Withdrawal in Delirium TremensAXIS II NoneAXIS III Leptospirosis in Weil’s Syndrome

r/o Typhoid EncephalopathyMultiple Electrolyte ImbalanceAlcohol Liver Disease

AXIS IV Medical IllnessAXIS V GAF 21-30

DSM-IVDIAGNOSTIC

CRITERIAAlcohol WithdrawalDelirium

DSM-IV-TR Diagnostic Criteria for Alcohol WithdrawalA. Cessation of (or reduction in) alcohol use that has been heavy

and prolonged. B. Two (or more) of the following, developing within several hours to a few

days after Criterion A: 1. autonomic hyperactivity2. increased hand tremor 3. insomnia 4. nausea or vomiting 5. transient visual, tactile, or auditory hallucinations or illusions 6. psychomotor agitation 7. anxiety 8. grand mal seizures

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-IV-TR Diagnostic Criteria for Substance (Alcohol) Withdrawal DeliriumA. Disturbance of consciousness with reduced ability to

focus, sustain, or shift attention. B. A change in cognition or the development of a

perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.

Diagnostic Criteria for Delirium Due to Multiple EtiologiesA. Disturbance of consciousness with reduced ability to

focus, sustain, or shift attention. B. A change in cognition or the development of a perceptual

disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

DELIRIUM Delirium is a medical emergency. Greater morbidity and mortality. Often referred to a psychiatrist because of

presenting psychiatric symptomatology.

CLINICAL SYMPTOMS OF DELIRIUM Intermittent disorientation to time or place Easy distractibility by irrelevant stimuli Mumbling or muttering (dysarthric speech) Hyper- or hypoactivity (agitation or hypersomnolence) “Sundowning” (increased confusion in the early evening),

or a subjective feling of confusion Illusions and misperceptions or a predominance of visual

hallucinations Extreme emotional lability Sudden inability to remember the events of the previous

day Transient difficulties in word-finding or disorganized

speech

Differences in Pyschotic Symptoms in Psychiatric and Neurologic Disease

SYMPTOM PSYCHIATRIC DISORDER

NEUROLOGIC DISORDER

Delusions Fixed, with more stable themes and elaborate contents, bizarre

Transient, less systematized, “homely”

Auditory Hallucinations

Prominent Accusatory in schizophrenia, mood-congruent in bipolar disorder of depression

Less commonOften ill-developed

Visual Hallucinations

Less common; typically related to delusional themes, usually frightening

Common in Alzheimer’s and Parkinson’s. Often not frightening. Usually associated with delusions.

Tactile Hallucinations

Rare A hallmark of delirium

Differences in Pyschotic Symptoms in Psychiatric and Neurologic Disease

SYMPTOM PSYCHIATRIC DISORDER

NEUROLOGIC DISORDER

Incoherent or neologistic speech

Meaning of neologisms tend to be consistent and context-specific

“Word salad” more generalized and inconsistent, characteristic aphasic symptoms per syndrome

Bizarre behavior May be related to delusional themes and tend to be stereotyped

Little organization or purpose; often sporadic

DISCUSSIONTyphoid Encephalopathy

Typhoid Fever AKA Enteric fever Potentially fatal multisystemic illness caused

primarily by Salmonella typhi Caused by ingesting food or water contaminated

with feces or urine containing the bacterium. Classic Presentation: fever, malaise, diffuse

abdominal pain, and constipation Untreated typhoid fever may progress

to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset.

Typhoid Encephalopathy Typhoid state, muttering delirium,

coma vigil Diffuse encephalopathy is a well-recognized

entity in typhoid fever Occurs in 10-15% of typhoid fever cases Typically occurs in the third week of illness Exact cause is unclear, but may be due to

release of endotoxins

Typhoid Encephalopathy Clinical Manifestations: decreased

sensorium, usually apathetic but arousable, may be severely agitated, delirious, or obtunded

Prognosis: decreased sensorium with shock is associated with high mortality. Survivors may be left with long-term or permanent neuropsychiatric complications.

The ‘typhoid state’ or ‘coma vigil’ supervenes and the prognosis is now grave. The patient lies on his back,

too weak to move, unconscious of his surroundings, his trembling hands

picking endlessly at the bedclothes, his eyes deceptively bright, but seeing little. He may continually whisper to himself until the coma

deepens, his movements cease, and the death rattle heralds the final

stage’.

1980’s Case Narrative

Treatment of Typhoid Fever With antibiotics, usually fluoroquinolones. Alternatives: chloramphenicol, amoxicillin and

trimethoprim–sulfamethoxazole Unfortunately, resistance of S. typhi strains to

all of these drugs is becoming more common, particularly in Asia, the Middle East and Latin America.

In resistant cases, consideration is given to a longer duration of quinolone therapy or to treatment with azithromycin or a third generation cephalosporin.

DISCUSSIONAlcohol Withdrawal

Ethanol Enhance inhibitory effects of GABA at GABA-

A receptors Blocks the NMDA subtype of glutamate, an

excitatory amino acid (EAA) receptor

Chronic Exposure: tolerance to ethanol by enhancing EAA neurotransmission and NMDA receptor upregulation

Effects of Chronic Alcoholism on the Brain Neurotoxic Shrinkage of the brain owing to loss of both

white and gray matter (Kril & Halliday, 1999) Reduces brain metabolism and this

hypometabolic state rebounds to a level of increased metabolism during detoxification

DSM-IV-TR Diagnostic Criteria for Alcohol WithdrawalA. Cessation of (or reduction in) alcohol use that has been heavy and

prolonged. B. Two (or more) of the following, developing within several hours to a few

days after Criterion A: 1. autonomic hyperactivity2. increased hand tremor 3. insomnia 4. nausea or vomiting 5. transient visual, tactile, or auditory hallucinations or illusions 6. psychomotor agitation 7. anxiety 8. grand mal seizures

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-IV-TR Diagnostic Criteria for Substance (Alcohol) Withdrawal DeliriumA. Disturbance of consciousness (i.e., reduced clarity of

awareness of the environment) with reduced ability to focus, sustain, or shift attention.

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.

Diagnostic Criteria for Delirium Due to Multiple EtiologiesA. Disturbance of consciousness (i.e., reduced clarity of

awareness of the environment) with reduced ability to focus, sustain, or shift attention.

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

Alcohol Withdrawal Syndrome Abrupt withdrawal of ethanol

Hyperexcitable state

Ethanol withdrawal syndrome Excitotoxic neuronal death

Signs and Symptoms Restlessness, irritability, anxiety, agitation Anorexia, nausea, vomiting Tremor, elevated heart rate, increased

blood pressure Insomnia, intense dreaming, nightmares Poor concentration, impaired memory and

judgment Increased sensitivity to sound, light, and

tactile sensations

Signs and Symptoms Hallucinations – auditory, visual, or tactile Delusions, usually of paranoid or

persecutory varieties Grand mal seizures Hyperthermia – high fever Delirium with disorientation with regard to

time, place, person, and situation Fluctuation in level of consciousness

Delirium Tremens Disturbance of consciousness with

reduced ability to focus, sustain, or shift attention, delirium, confusion, and frank psychosis.

Change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

Management: Alcohol Withdrawal Syndrome/Delirium Tremens

1. Monitor VS Watch out for hypotension, hyperthermia

2. Correct electrolyte imbalance

3. Control withdrawal symptoms

Medications used in AWS/DT Thiamine Benzodiazepines Antipsychotics Antiepileptics Ancillary Medications:

◦Clonidine◦Beta blockers

Thiamine 50–100 mg of thiamine daily Coenzyme in the pyruvate dehydrogenase

complex - accelerates the conversion of pyruvate to acetyl-coenzyme A (acetyl-CoA)

Cofactor for a-ketoglutarate dehydrogenase, a second enzyme in the Krebs cycle

Cofactor for transketolase, an enzyme in the pentose phosphate pathway

Benzodiazepines Promote the binding of GABA to the GABA A

sub type of the GABA receptors enhancing the frequency of GABA chloride channel openings

Treatment of choice

BDZ with longer half-lives(diazepam or chlordiazepoxide) Diazepam 10 mg IV initially and

repeated once or twice at 20- to 30-min intervals until the patient is calm but awake

Symptom-triggerred - Dose is increased if signs of withdrawal escalate, and the medication is withheld if the patient is sleeping or shows signs of increasing orthostatic hypotension.

Benzodiazepines with short half-lives (lorazepam)

Single dose used to prophylactically suppress seizures

patients with serious liver impairment or evidence of preexisting encephalopathy or brain damage

can produce rapidly changing drug blood levels and must be given every 4 h to avoid abrupt fluctuations that may increase the risk for seizures

Adverse Effects Oversedation, ataxia, and confusion, Potential interactions with alcohol can lead

to coma and respiratory suppression, motor incoordination and abuse of the medications

Meta-analysis: no significant difference between benzodiazepines and alternative drugs in terms of adverse events (common OR 0.67, 95% CI 0.34-1.32) or dropout rates (common OR 0.68, 95% CI 0.47-0.97)

Benzodiazepines for alcohol withdrawal. Cochrane Database of Systematic Reviews, Issue 3, 2009

As the number of previous alcohol withdrawals

increases , the severity of withdrawal increases and

responsiveness to benzodiazepines decreases

Antipsychotics Not the 1st line of treatment control extreme agitation, hallucinations,

delusions, and delirium during alcohol withdrawal

May decrease threshold of seizure Haldol, 1 mg every 2 hours, until the

patient's symptoms of psychosis begin to disappear

Antiepileptic Drugs Carbamazepine

decrease the severity of withdrawal symptoms comparable to the benzodiazepines in terms of adverse events, and was equally as effective as lorazepam in decreasing the symptoms of alcohol withdrawal

subsequent systemic review of a heterogeneous group of trials was unable to draw definite conclusions

Polycarpou A, Papanikolaou P, Ioannidis J, Contopoulos-Ioannidis D. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev 2005;(3):CD005064.

• Insufficient evidence to support its use as the sole treatment for AWS or in the prevention of seizure

Beta Blockers Propranolol and atenolol Reduce heart rate, blood pressure, and

tremor

Alpha2 agonist Lofexidine and clonidine Blocks autonomic outflow centrally Reduce severity of withdrawal symptoms