Thomas D. Sabin

Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well, except for occasional migraine headaches, until 7 weeks earlier, when generalized, diffuse headache developed. It was most severe in the occipital region, with associated neck stiffness, sensitivity to sounds, intermittent blurred vision, nausea, and vomiting. There were no prodromal symptoms or visual scotoma, which had occurred routinely with her migraines, and the pain did not diminish in response to her usual migraine treatment. During the next 10 days, she was seen multiple times in the emergency departments of other hospitals. A computed tomographic (CT) scan of the brain obtained without the administration of gadolinium reportedly showed inflammatory changes in the left maxillary and ethmoid sinuses but was otherwise normal. Medications, including butalbital, oxycodone, hydrocodone, ibuprofen, sumatriptan, indomethacin, acetaminophen, and caffeine, were administered, with transient partial relief from pain. Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of depersonalization developed. Five and a half weeks before admission to this hospital, increasing visual disturbances that were thought to be visual hallucinations developed, with increasing confusion. On evaluation in a local emergency department, laboratory tests revealed negative results in tests for Lyme disease and syphilis. She was admitted to an inpatient psychiatric facility. The patient had a history of migraine headaches, obesity, asthma, and seasonal allergies. She smoked cigarettes and drank up to six alcoholic beverages on weekends. Several days before the onset of symptoms, she had attended a party and taken a drug that was reported to contain cocaine, crystal methamphetamine, ecstasy, and possibly salvia. On admission to the psychiatric hospital, her speech was initially fluent and appropriate but became garbled and incoherent; abnormal movements developed, including hyperextension of the arms and movements of the mouth. Antipsychotic medications, including haloperidol, risperidone, benztropine, lorazepam, olanzapine, valproic acid, and quetiapine, were administered, without improvement. Fever developed, and the serum level of creatine kinase was reportedly elevated. On the fifth day, she was transferred to another hospital because of suspected neuroleptic malignant syndrome. Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

Case records of the Massachusetts General Hospital. Case 26-2008. A 26-year-old woman with headache and behavioral changes.

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well, except for occasional migraine headaches, until 7 weeks earlier, when generalized, diffuse headache developed. It was most severe in the occipital region, with associated neck stiffness, sensitivity to sounds, intermittent blurred vision, nausea, and vomiting. There were no prodromal symptoms or visual scotoma, which had occurred routinely with her migraines, and the pain did not diminish in response to her usual migraine treatment. During the next 10 days, she was seen multiple times in the emergency departments of other hospitals. A computed tomographic (CT) scan of the brain obtained without the administration of gadolinium reportedly showed inflammatory changes in the left maxillary and ethmoid sinuses but was otherwise normal. Medications, including butalbital, oxycodone, hydrocodone, ibuprofen, sumatriptan, indomethacin, acetaminophen, and caffeine, were administered, with transient partial relief from pain. Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of depersonalization developed. Five and a half weeks before admission to this hospital, increasing visual disturbances that were thought to be visual hallucinations developed, with increasing confusion. On evaluation in a local emergency department, laboratory tests revealed negative results in tests for Lyme disease and syphilis. She was admitted to an inpatient psychiatric facility. The patient had a history of migraine headaches, obesity, asthma, and seasonal allergies. She smoked cigarettes and drank up to six alcoholic beverages on weekends. Several days before the onset of symptoms, she had attended a party and taken a drug that was reported to contain cocaine, crystal methamphetamine, ecstasy, and possibly salvia. On admission to the psychiatric hospital, her speech was initially fluent and appropriate but became garbled and incoherent; abnormal movements developed, including hyperextension of the arms and movements of the mouth. Antipsychotic medications, including haloperidol, risperidone, benztropine, lorazepam, olanzapine, valproic acid, and quetiapine, were administered, without improvement. Fever developed, and the serum level of creatine kinase was reportedly elevated. On the fifth day, she was transferred to another hospital because of suspected neuroleptic malignant syndrome. Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

Temporal arteritis-like presentation of carotid atherosclerosis.

A 68 year-old woman presented with a two-week history of amaurosis fugax, ipsilateral fronto-temporal headache and jaw claudication suggesting carotid giant cell arteritis. However, this syndrome proved to be due to atherosclerosis causing complete occlusion of the external carotid artery at its origin and narrowing of the internal carotid artery. Combined external and internal carotid endarterectomy relieved the symptoms. The symptom complex of temporal arteritis may be rarely mimicked by carotid atherosclerotic occlusive disease.

Case 26-2008

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well, except for occasional migraine headaches, until 7 weeks earlier, when generalized, diffuse headache developed. It was most severe in the occipital region, with associated neck stiffness, sensitivity to sounds, intermittent blurred vision, nausea, and vomiting. There were no prodromal symptoms or visual scotoma, which had occurred routinely with her migraines, and the pain did not diminish in response to her usual migraine treatment. During the next 10 days, she was seen multiple times in the emergency departments of other hospitals. A computed tomographic (CT) scan of the brain obtained without the administration of gadolinium reportedly showed inflammatory changes in the left maxillary and ethmoid sinuses but was otherwise normal. Medications, including butalbital, oxycodone, hydrocodone, ibuprofen, sumatriptan, indomethacin, acetaminophen, and caffeine, were administered, with transient partial relief from pain. Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of depersonalization developed. Five and a half weeks before admission to this hospital, increasing visual disturbances that were thought to be visual hallucinations developed, with increasing confusion. On evaluation in a local emergency department, laboratory tests revealed negative results in tests for Lyme disease and syphilis. She was admitted to an inpatient psychiatric facility. The patient had a history of migraine headaches, obesity, asthma, and seasonal allergies. She smoked cigarettes and drank up to six alcoholic beverages on weekends. Several days before the onset of symptoms, she had attended a party and taken a drug that was reported to contain cocaine, crystal methamphetamine, ecstasy, and possibly salvia. On admission to the psychiatric hospital, her speech was initially fluent and appropriate but became garbled and incoherent; abnormal movements developed, including hyperextension of the arms and movements of the mouth. Antipsychotic medications, including haloperidol, risperidone, benztropine, lorazepam, olanzapine, valproic acid, and quetiapine, were administered, without improvement. Fever developed, and the serum level of creatine kinase was reportedly elevated. On the fifth day, she was transferred to another hospital because of suspected neuroleptic malignant syndrome. Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

De Novo Headache During Pregnancy and Puerperium.

Background:A conservative estimate is that approximately 5% of pregnancies are affected by de novo headache, that is, new-onset or new-type headache. Objectives:(1) Summarize the available literature, which is exclusively neurological, regarding de novo headache during the third trimester of pregnancy and puerperium; and (2) review the common pathologies of pregnancy and puerperium that may be relevant to de novo headache, with focus on the first and second trimester. We obtained the literature through a search of PubMed and references of the retrieved publications, without time limit. Results:Aneurysmal subarachnoid hemorrhage and idiopathic intracranial hypertension occur at the same rate during pregnancy and puerperium as otherwise, but symptomatic intracranial hypertension due to dural venous-sinus thrombosis is increased during the third trimester and puerperium. Stroke occurrence, whether arterial or venous, does not seem increased during pregnancy and puerperium but when stroke does occur, it is mostly during the third trimester and puerperium. Immediate postpartum headache is commonly either tension-type headache or migraine; when due to spinal-fluid hypovolemia, apart from epidural or spinal anesthesia, a labor-related dural tear should be considered. Of the medical conditions associated with pregnancy, hypothyroidism, anemia, and hypertension may have to be considered as possible causes of de novo headache. Conclusion:De novo headache during pregnancy is relatively common and almost always leads to neurological referral.

NEUROLOGICAL MANIFESTATIONS OF LEPROSY

BACKGROUND- Leprosy affects millions worldwide and is surprisingly common in the United States. Leprous neuritis is the most common treatable neuropathy.REVIEW SUMMARY- Leprosy is the only disease in which bacteria regularly invade peripheral nerves, with a predilection for Schwann cells. Because of a low temperature optimum for mycobacterial growth, nerve damage occurs in cool areas, leading to a unique temperature-linked neuropathy. Recognition of the neurologic features permits early diagnosis and effective treatment with rifampin, dapsone, and clofazimine. Leprosy occurs in high-, medium-, and low-resistance forms. Superimposed reactions are immunologic phenomena that profoundly affect the degree of nerve damage. Stigma and rehabilitation are important aspects of leprosy.CONCLUSION- Leprosy produces a characteristic neuropathy easily recognizable by a neurologist.

Neurologic Complications of Leprosy

Leprosy is an important cause of nontraumatic peripheral neuropathy. Its main clinical features are anesthetic skin lesions and peripheral neuropathy, but skin lesions are sometimes absent. The different types of leprosy (leprous neuritis and lepromatous, tuberculoid, and borderline lepsrosy), pathology, diagnosis, and treatment of leprosy are discussed in this chapter.

Acute Pancerebellar Syndrome During Recovery from Alcohol Withdrawal

An acute pancerebellar syndrome developed in a 40‐year‐old, alcoholic, malnourished woman while she was recovering from alcoholic hepatitis in the hospital. Brain magnetic resonance imaging showed a lesion in the pons and helped identify this syndrome as central pontine myelinosis despite the lack of typical neurological signs and fluxes of serum sodium levels.