Acute Confusional State and Psychosis

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					Case and Discussion:
 Chronic and Acute
 Confusional States
       Connie Chen, MD
Neurology Consultants of Dallas

 Case presentation
 Differential diagnosis
 Clinical approach
 Results and findings
 Follow-up
 Discussion
            Case Presentation
   61 yo woman
    – episode of presyncope
    – “wobbly” when standing
    – “slow thinking” over 6 months
    – noted after administration of BP meds (SBP
      200’s lowered to 120’s)
 NRO exam non-focal. MS not extensively
  tested, some memory loss noted
 Hyponatremic: Na=117
           Case Continued
 Diuretic stopped
 BP raised slightly
 PT d/c’d to home after Na normalized
               Case Continued
   2 weeks later
    – Episodic worsening of confusion
    – Lost while driving
    – Worsening short-term memory
    – Episodes of paranoia
    – New delusions:
        CT scanner trying to transport her to the future
        Aliens trying to abduct daughter
        After watching “Manchurian Candidate,” she was
         also involved in a conspiracy
              Case Continued
   NRO exam:
    – MS:
       Poor memory, attention, not oriented
       Labile affect
       Intact calculations, language
       Delusional

    – CN, motor, sensation, cerebellar, and gait are
         Differential diagnosis:
        Chronic confusional state
   Progressive decline of memory, cognition:
    – Degenerative dementias
    – Multi-infarct dementia
    – Chronic infection (TB meningitis, syphilis, HIV)
    – Hypothyroidism
    – Vitamin deficiencies (B12, thiamine)
    – Toxins
    – Other: seizures, neoplastic, paraneoplastic,
         Differential diagnosis:
         Acute confusional state
 Delirium
  – “Metabolic states”:
      Medications/drugs
      Endocrine: thyroid, glucose, hyper/hypoadrenalism
      Electrolytes: Na, Ca
      Vitamins: B12, thiamine
      Organ failure: liver, renal (uremia, “dialysis
       disequilibrium”), respiratory failure (hypoxia)
   Acute Confusional State
– Cerebrovascular:
   stroke/TIA
   hypertensive encephalopathy, hypotension
   DIC, TTP
– Infectious: meningitis
– Seizures
– Head trauma
– Neoplasm
– Other: (Systemic disease: rheumatologic,
             Clinical approach
 Systematic approach
 Indications for studies
 Don’t stop with one diagnosis:
    – “Think outside the box”
    – “What am I missing?”
    – Tailor your work-up, you can always expand
    Our case: Results and Findings
   Chronic confusional state (>6 month decline)
    – Degenerative dementias:
        Diagnosis of exclusion
        Requires memory loss in addition to another “cognitive
         sphere” with functional decline
    – Multi-infarct dementia: no evidence of infarction.
    – Chronic infection: LP negative ( mild protein
      elevation), RPR negative, HIV negative.
    – Hypothyroidism: nl TSH
    – Vitamin deficiencies (B12, thiamine): low B12, normal
    – Toxins: negative tox screen
             Results Continued
   Acute confusional state:
    – Metabolic:
        Meds: none
        Endocrine: TSH normal, normo-glycemia
        Infections: LP negative except elevated protein,
         RPR negative, HIV negative.
        Vitamins: B12 low but homocysteine normal (MMA
         pending), thiamine given.
        Electrolytes: Na 131, dropped to 127.
        Organ failure: organs normal, no respiratory
            Results Continued
 Cerebrovascular: no focality to suggest stroke/TIA, not
  hyper or hypotensive, no evidence DIC/TTP.
 Seizure: left temporal sharp wave. No seizure.
 Neoplasm: normal head CT.
       What else am I missing?
   Delirium with new onset pyschosis :
    – Antiphospholipid antibody syndrome
    – Limbic encephalitis (paraneoplastic syndrome)
    – Porphyria
               More Results
   ESR, ANA, anticardiolipin antibodies
                More Results
   Chest CT:
    – right paratracheal node
    – 0.8 cm nodular opacity right upper lobe.

   Biopsy of node: small cell lung cancer.
 Treatment with XRT and CMTx.
 Psychotic symptoms resolved.
 Memory loss remains.

   Limbic encephalitis:
       “a paraneoplastic syndrome marked by
    degeneration of neurons in the medial
    temporal lobe.”
        Limbic encephalitis
– Incidence: unknown (rare)
– Symptoms:
   Acute confusional states
   Memory loss
   Seizures
   “Psychiatric” symptoms
   Dementia
– Antineuronal antibodies: anti-Hu, anti-Ta,
  (anti-Ma, others)
        Limbic encephalitis
– Often presents before tumor diagnosis
– Tumor associations
   Lung (small cell, non-small cell)
   Testicular
   Breast
              Limbic encephalitis:
 EEG: temporal lobe seizures, sharp waves,
 CSF: (can be normal)
        Mild pleocytosis
        Mildly elevated protein
   Radiographic:
    – MRI: (can be normal)
        medial temporal lobe: “bright” on T2, enhances
         with contrast.
        brainstem
        hypothalamus
    – ** r/o HSV encephalitis**
              Limbic encephalitis:
 Treatment: underlying tumor
 Immune modulatory treatments attempted:
    –   Steroids
    –   Cyclophosphamide
    –   IV IG
    –   Plasmapheresis
   Improvement of symptoms only with tumor

   If diagnosed- search for tumor!