Jason P. Caplan

Steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) or Hashimoto's encephalopathy: a case and review.

BACKGROUND Steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a condition of presumed autoimmune etiology that can present with a variety of neuropsychiatric signs and symptoms. OBJECTIVE To illustrate the clinical findings and treatment options of this underdiagnosed condition. METHOD We present a case of a patient diagnosed with SREAT and review the available literature including management of psychiatric symptoms. RESULTS Little has been reported about the psychiatric management of patients with SREAT. CONCLUSION Psychiatrists practicing in the general hospital setting should be aware of this often unrecognized entity to ensure accurate diagnosis and timely treatment.

Pseudopseudoseizures: Conditions That May Mimic Psychogenic Non-Epileptic Seizures

BACKGROUND Video electroencephalography (vEEG) has proven to be a valuable tool in the differentiation of pseudoseizures or psychogenic non-epileptic seizures (PNES) from epileptic seizures. Clinicians should, however, be aware of a number of conditions that may be misdiagnosed as pseudoseizures. OBJECTIVE To review a number of somatic conditions that can present with disturbances of consciousness and unusual motor activity without epileptiform findings on vEEG. METHOD We report a case of a young woman who presented with a number of neuropsychiatric symptoms, including episodic posturing and rhythmic movements. The absence of epileptiform findings on vEEG resulted in a diagnosis of conversion disorder with pseudoseizures. She was ultimately diagnosed with N-methyl-D-aspartate (NMDA) receptor autoimmune encephalitis (AIE) secondary to an ovarian tumor. AIE and other potential mimics of pseudoseizures are discussed. RESULTS A number of somatic conditions can present with symptoms that may be misinterpreted as pseudoseizure.

Self-Mutilation and Biblical Delusions: A Review

OBJECTIVE To review the literature for cases of deliberate self-harm that directly reference Bible verses as a motivation for action and discuss predictive factors of such behaviors and post-injury management strategies. METHODS Sixteen cases of self-mutilation prompted by Biblical verses were found in the existing literature. The authors also describe a novel case of penile amputation prompted by a verse from the Gospel of Matthew. RESULTS Four biblical verses associated with self-mutilation were found, all from the Gospel of Matthew. All patients presented with a diagnosis of psychosis at the time of the event. Other common themes include substance abuse, guilt over sexual acts, absence of pain or regret, and destruction of the severed body part. CONCLUSIONS Patients with symptoms of psychosis may misinterpret various verses from the Gospel of Matthew as instructions to engage in self-injurious behavior. Psychiatrists should be aware of these four verses to understand their significance and potentially forestall these behaviors.

Posterior Reversible Encephalopathy Syndrome

BACKGROUND The presentation of posterior reversible encephalopathy syndrome (PRES) features neuropsychiatric symptoms in the context of predominantly white matter cerebral edema in the setting of a diverse variety of underlying clinical entities. OBJECTIVE To illustrate the presentation and diagnostic strategy for this under-recognized condition. METHOD We present two cases of PRES and review the available literature. RESULTS PRES may be due to a number of underlying conditions, but typically presents with symptoms consistent with delirium. CONCLUSIONS Psychiatrist practicing in the general hospital should be aware of the presentation and appropriate work-up of PRES to forestall serious potential sequelae.

Zolpidem-Associated Parasomnia with Serious Self-Injury: A Shot in the Dark

Benzodiazepine receptor agonists (BzRAs) are a commonly prescribed class of medication used in the treatment of insomnia. These medications have been previously associated with various complex sleep behaviors. We report the case of a man admitted with a self-inflicted gunshot wound to the head potentially resulting from complex sleep behavior associated with the use of a BzRA.

A Naturalistic On-Off-On Trial of Dextromethorphan/Quinidine for Agitation Associated with Cerebellar Injury

Mr. A, a 47 year-old man with a complicated medical history including HIV and neurovascular syphilis, presented to an urban academic medical center with complaints of headache, vertigo, facial numbness, and intractable hiccups. He reported being awakened from sleep by a loud popping sound coming from the back of his neck with immediate onset of his presenting symptoms. Exam was remarkable for dysarthric speech and copious oral secretions that he was unable to swallow. Magnetic resonance imaging of the brain revealed areas of restricted diffusion in the left inferior cerebellar hemisphere and the left lateral aspect of the medulla consistent with an acute infarct of the left posterior inferior cerebellar artery (PICA). Subsequent CT angiography revealed an occlusion of the left vertebral artery thought to be due to dissection. Psychiatry was consulted on the 13th hospital day due to worsening episodic agitation that had begun on the 7th hospital day. He was noted to have very poor frustration tolerance, often becoming upset with his dietary restrictions and perceived delay in responses to his requests. He had pulled out his intravenous (IV) lines on several occasions and had pushed over his IV pole. Psychiatric consultation had finally been prompted by nursing becoming upset that Mr. A was watching pornography on his laptop

A patient with multiple episodes of rhabdomyolysis induced by different neuroleptics.

Rhabdomyolysis is a common but potentially lethal clinical syndrome consisting of acute, diffuse muscle breakdown and muscle fiber necrosis with leakage of potentially toxic muscle constituents into blood. This process has the potential to produce myoglobinuria and acute renal failure, causing death in about 10% of cases. Etiologies of rhabdomyolysis include alcohol abuse, muscle compression, muscle overexertion, and inherited disorders ofmusclemetabolism. There are also published case reports of rhabdomyolysis with neuroleptic use. We report a unique case of a patient with schizoaffective disorder who, over the course of 2 years, developed rhabdomyolysis on multiple occasions associated with 4 different neuroleptics. To our knowledge, this is the first reported case of rhabdomyolysis induced by multiple different neuroleptics in the same patient.

Get the lead out: potential progressive localized neural injury from retained cerebral bullet fragments without systemic toxicity.

The toxidromes of lead and copper have been described clinically since the 19th century. Since then, a number of clinical reports have described disturbances of neurocognitive function in patients with retained bullet fragments and significant blood or cerebrospinal fluid levels of these heavy metals. Lead neurotoxicity has been attributed to disruption of intracellular signaling pathways and the production of free radicals. Copper neurotoxicity is due to severe inflammation, resulting in demyelination and axonal degeneration. Here, we describe the case of a 43-year-old white man with retained intracerebral bullet fragments who presented with a 6-month history of accelerated decompensation in cognitive and functional ability with undetectable peripheral lead levels.

Phantom Shocks and Automated Implantable Cardioverter Defibrillators

An automatic implantable cardioverter defibrillator (AICD) is a life-saving device that has become the standard of care for primary and secondary prevention of life-threatening ventricular arrhythmias in patients predisposed to these conditions. As AICD placement has become more commonplace, the phenomenon of “phantom shocks (PSs)” (in which the patient perceives that they are being shocked by their AICDwithout any objective proof that the shock occurred) has similarly become more prevalent. Theories on the etiology of PSs reported in the literature have focused on their representation of a posttraumatic re-experience phenomenon. Here, we present the case of a woman with PSs so severe that they precipitated a suicide attempt.

A Case of Nerium Oleander Toxicity: A Thorny Predicament

Oleander plants are decorative, thorny shrubs that are commonly found in many parts of the world, including large areas of the southern United States. Regardless of the species of oleander, they contain significant concentrations of cardiac glycosides that may prove fatal if ingested. The effects of oleander poisoning have previously been reported in the toxicology and emergency medicine literature but, to our knowledge, have not previously been reported in the context of psychiatric care. Here we report the case of a man who presented with a variety of symptoms after eating leaves from an oleander plant.