Nabil Kotbi

A case of late-life onset mania during Varenicline assisted smoking cessation

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Understanding the dangers of synthetic cannabinoids

H ere we present the case of a substance-induced mood disturbance resulting from the use of synthetic cannabinoids. A 51-year-old man with a 30-year history of cannabis use and no psychiatric admissions presented with worsening passive suicidal ideation, anhedonia, and poor concentration. He had no family history of mood disorders. In addition, he had mood lability, agitation, irritability, and paranoia. Physical examination, laboratory examinations, and brain magnetic resonance imaging results were within normal limits. Urine toxicology was positive only for cannabis. He admitted to daily marijuana use; however, he indicated that 3 weeks before admission, he switched from marijuana to synthetic cannabis. He experienced no withdrawal symptoms from cessation of marijuana and found synthetic cannabis to have stronger euphoric and relaxation effects, only needing to smoke 1 joint, which was half of his typical daily use. He also mentioned the advantages of minimal odor and user-friendly delivery (smoked from a small pin-like device). He became more impulsive with subsequent interpersonal difficulties. He gradually improved with 200 mg of quetiapine taken over 1 week and attained euthymic mood with complete cessation of agitation, paranoia, and suicidal thoughts. This clinical improvement was sustained without psychotropics several months after discharge despite continued marijuana use and in the absence of any synthetic cannabinoids use.

Ventromedial syndrome with normal cognitive functioning in vascular depression.

Earlier, we described a late-life depression-executive dysfunction syndrome associated with disability (1). Microstructural white matter abnormalities, common in this syndrome, are principally caused by cerebrovascular changes and contribute to executive dysfunction and resistance to antidepressants (2). We recently treated a 71 year-old woman in the third episode of early-onset (mid-thirties) major depression, hospitalized after an overdose. She had a dysexecutive behavioral syndrome, prominent hyperintensities on MRI (Figure 1), but no impairment on executive function tests. She presented with mood lability and poor monitoring of her own behavior, i.e. repetition, distractibility, and impulsivity. She performed in the average to superior range on tasks of processing speed (Trails A 73rd percentile), cognitive inhibition (Stroop 66th percentile), set-shifting (Trails B 96th percentile; Wisconsin Card Sort 61st percentile), and planning (Tower Test, 75th percentile). She was partially aware of her pathology, noting “I want to change the habit of speaking out without thinking and acting impulsively”. Her husband’s report on the Frontal System Behavior Rating Scale (3) showed major abnormalities in “disinhibition” with much milder abnormalities in the “dysexecutive” and “apathy” domains. Figure 1 Patient’s MRI Findings This patient’s behavior was consistent with ventromedial cortex (VMPFC) dysfunction. Lesions in this area may disconnect frontal monitoring systems from limbic output resulting in prominent mood lability, behavioral disinhibition, and inappropriate behavior and judgment (4). Patients with VMPFC dysfunction may have intact executive functioning primarily served by dorsolateral prefrontal cortex and dorsal anterior cingulate circuitry (4). Behavioral abnormalities related to the VMPFC have seldom been investigated in late-life depression. We recently conducted a cluster analysis of 52 adults with late-life depression and identified three patient subgroups. Cluster 1 (n=20) performed poorly on a task requiring VMPFC integrity (Iowa Gambling) but performed well on cognitive control tasks (Stroop Color Word, Tower), and had no apathy. Cluster 2 (n=19) performed well on the Iowa, had impaired performance on the Stroop and Tower, and had mild apathy. Cluster 3 (n=13) performed well on the Iowa, Stroop, and Tower but had significant apathy. Impairment in risk-sensitive decision-making has been documented in older suicide attempters (5), suggesting that select patients may present with VMPFC impairment. We suggest that disinhibited behavior, dissociable from cognitive control dysfunction, characterizes a subgroup of late-life depression whose neurobiology and treatment response require investigation.

Rhabdomyolysis associated with mania in late life.

We report a case of rhabdomyolysis associated with acute mania in a 74 year old man. What makes this case noteworthy is the development of multiple episodes of rhabdomyolysis in the context of excessive physical exercise in an old man who was never diagnosed with a psychiatric illness. Rhabdomyolysis is a potentially fatal condition that follows skeletal muscle injury and can lead to serious complications such as renal failure (1) (2). Skeletal muscle injury, traumatic or non-traumatic, may trigger the release of intracellular contents including creatine phosphokinase (CPK) and myogobin which is manifested by elevated serum CPK and myoglobinuria (1) (2). The classic triad of rhabdomyolysis is muscle pain, weakness and dark urine (1) (2). In a study of 77 patients aged 21–85 years who developed rhabdomyolysis, 8 patients of unspecified age died (3). Delay in diagnosis and treatment of rhabdomyolysis may increase the risk of mortality (1) (2) therefore, early identification and intervention are crucial for a good outcome. The prevalence of rhabdomyolysis is unknown and considered rare, however, descriptions are confined mostly to case reports (1) (2). The incidence of rhabdomyolysis in psychiatric patients is not known (1). Nevertheless, several risk factors make psychiatric patients more vulnerable to develop rhabdomyolysis and these factors include catatonia, agitation, alcohol abuse, and neuroleptic medications (1) (2) (4) (5).

Opana ® ER induced thrombotic thrombocytopenic purpura

We present the case of a patient who developed thrombotic thrombocytopenic purpura (TTP) following intravenous injection of Opana® ER. TTP reemerged after three months of abstinence with Opana misuse. This case report brings awareness to the possibility of developing TTP in those who misuse Opana, which is a growing concern.

Mania, cocaine, and rhabdomyolysis: a case report.

We present the case of recurrent rhabdomyolysis dur-ing untreated manic episodes complicated by concurrentcocaine use. Rhabdomyolysis is the rapid break downof striated muscle fibers, which can result in potentiallylife-threatening conditions, including hypovolemia, com-partment syndrome, arrhythmias and cardiac arrest, dis-seminated intravascular coagulation (DIC), hepatic dys-function, acidosis, and acute renal failure.

A 49-Year-Old Male with Progressive Disorganization and Unipolar Depression

The patient, a 49-year-old, successful businessman, was first diagnosed with bipolar disorder at the age of 35 years. He underwent trials of combination therapy including lithium, divalproex, venlafaxine, escitalopram, olanzapine, and quetiapine but never achieved full remission; symptoms of dysphoria, irritability, and impulsive behavior remained. However, he was able to continue working, and his marriage was stable. At age 37 years, he and others noticed decrements in his ability to organize his work, and he became increasingly reliant on his assistant. By the age of 40 years, his organizational ability declined to the point that he required a second assistant while work demands remained stable. Over the course of 9 years, his symptoms changed from episodes of dysthymia and moderate hypomania to distinct episodes of depression with anhedonia and suicidal ideation, alternating with hyperthymia, grandiosity, and impulsivity while being maintained on divalproex, lamotrigine, and olanzapine. He eventually became volatile and had two separate altercations with the police leading to his hospitalization after the second event. On admission, he appeared hyperthymic and disinhibited. After a few days, these symptoms were rapidly replaced by profound sadness, psychomotor retardation, irritability, hopelessness, and suicidal ideation. Neuropsychological testing revealed deficits in executive function includ ing profoundly impaired planning, execution, organization, set shifting,

Two Women with History of Bipolar Disorder

Awoman presented with cannabis abuse, marital discord, and family history of unipolar and bipolar mood disorders. She developed her fi rst manic epi