A Case of Psychosis Due to Acute Hypocalcemia From Hypoparathyroidism

Abstract A 61-year-old female with past medical history of depression, hypoparathyroidism (hypoPtH), and hypothyroidism had disappeared from her home and was found wandering a few hours away with persecutory delusions, visual and auditory hallucinations. Serum calcium (Ca) was 6.3 mg/dL (range 8.6–10.2), albumin 3.7 g/dL (range 3.5–5.2) and ionized Ca 0.89 mmol/L (range 1.12–1.30). She was admitted and treated with Ca and calcitriol. Work-up for altered mental status was negative except for hypocalcemia (hypoCa) and scattered bilateral basal ganglia calcifications (BGC) with cortical and subcortical frontal lobe calcifications on CT. Psychiatry diagnosed delirium due to hypoCa. Acute psychosis resolved once Ca levels improved. Diagnosis of idiopathic hypoPtH was in 1997. Her regimen included Ca citrate 1500mg daily and 10 mcg of Forteo twice daily. She had skipped her medications for at least 2 days prior to presentation. Her medical records revealed that she was seen for severe depression, progressive gait abnormalities, slowed movements, and imbalance, in 2015. CT scan and MRI brain showed BGC. Her son gave a history of multiple admissions for psychosis, violence, delusions with agitation, and wandering at times when the patient was hypoCa, which was diagnosed as schizophrenia. Neuropsychiatric disturbances are commonly associated with hypercalcemia. Review of literature found a few case reports of psychosis and hypoPtH 1,2 BGC is common in hypoPtH. Psychotic symptoms due to BGC include auditory hallucinations, delusions of influence, paranoid states, and complex perceptual distortions.3,5 HypoCa is associated with cognitive impairment. Neurological manifestations tend to improve with Ca correction, but psychiatric symptoms do not improve substantially.4,5 Further studies are needed in hypoPtH with BGC to appropriately diagnose organic psychosis. This is important in management of the vicious cycle of psychiatric illness leading to noncompliance resulting in psychosis. Prevention of BGC will play a key role. References: 1. Finan M, Axelband J. This is your brain on calcium: psychosis as the presentation of isolated hypoparathyroidism. Am J Emerg Med. 2014;32:945.e1-4. 2. Ang AW, Ko SM, Tan CH. Calcium, magnesium, and psychotic symptoms in a girl with idiopathic hypoparathyroidism. Psychosom Med. 1995;57:299–302. 3. Burns K, Brodaty H. Fahr’s disease and psychosis. In: Sachdev PS, Keshavan MS, editors. Secondary schizophrenia. Cambridge: Cambridge University; 2010. p. 358–66. 4. Maiti A, Chatterjee S. Neuropsychiatric manifestations and their outcomes in chronic hypocalcaemia. J Indian Med Assoc. 2013;111:174–7. 5. Amara A, Novais C, Coelho M, Silva A, Curral R, Brandao I, Torres A. Organic psychosis due to hypoparathyroidism in an older adult: a case report. Braz. J. Psychiatry; 2016; 38(4)

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Possible Garcinia cambogia-Induced Mania With Psychosis: A Case Report

Journal of Pharmacy Practice ◽

10.1177/0897190017734728 ◽

2017 ◽

Vol 32 (1) ◽

pp. 99-102 ◽

Cited By ~ 5

Author(s):

David C. Nguyen ◽

Tysen K. Timmer ◽

Blair C. Davison ◽

Ian R. McGrane

Keyword(s):

Hospital Admissions ◽

Psychiatric Symptoms ◽

Case Reports ◽

Auditory Hallucinations ◽

Herbal Supplement ◽

Psychomotor Agitation ◽

Garcinia Cambogia ◽

Supplement Use ◽

History Of ◽

Mood Stabilization

Garcinia cambogia is a Southeast Asian fruit becoming increasingly popular as a weight management supplement. Hydroxycitric acid (HCA) is the primary active ingredient which demonstrates serotonergic- and muscarinic-enhancing properties via inhibition of selective serotonin reuptake and acetylcholinesterase. We report a young adult female with no history of bipolar disorder who developed mania and psychosis approximately 1 week following initiation of G cambogia and the Cleanse and Detox™ dietary supplement manufactured by Apex Vitality Health. She presented with a predominantly expansive mood, psychomotor agitation, disorganized and pressured speech, flight of ideas, grandiosity, delusions, and auditory hallucinations. Following discontinuation of G cambogia and the initiation of lithium and quetiapine, the patient experienced rapid and progressive mood stabilization and was discharged after 8 days. Seven previous case reports associating (hypo)mania and/or psychosis with G cambogia consumption have been published. The chronology of mania and/or psychosis onset may appear between 1 and 8 weeks following initiation of G cambogia. Psychiatric symptoms have resolved with G cambogia discontinuation in some instances and may not require chronic pharmacotherapy. Our report should encourage further research and case reports regarding this adverse event and the reconciliation of complete herbal supplement use at clinic visits and hospital admissions.

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861 Vascular dementia presenting as rapidly progressive dementia secondary to zolpidem

SLEEP ◽

10.1093/sleep/zsab072.858 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A335-A335

Author(s):

Cameron Barber ◽

Dylan Carroll ◽

Bhavani Suryadevara

Keyword(s):

Vascular Dementia ◽

Microvascular Disease ◽

Altered Mental Status ◽

Progressive Dementia ◽

Personality Changes ◽

The Us ◽

History Of ◽

Gait Abnormalities ◽

Scheduled Time ◽

Chronic Use

Abstract Introduction Rapidly progressive dementia is a condition with a wide differential which remains difficult to accurately diagnose. The potential pathologies responsible include thyroid, vitamin, and electrolytes abnormalities, infectious, and malignant causes. Vascular dementia, however, typically has a slow and insidious presentation. Zolpidem (Ambien) is among the top 50 prescribed medications in the US. Report of case(s) An 84-year-old Caucasian male with a past medical history of insomnia, and sleep apnea who is noncompliant with CPAP presented after a fall associated with altered mental status. He has taken zolpidem 10 mg nightly for over six years. The patient and wife reported notable personality changes beginning six months prior, as well as four months of progressively worsening auditory and visual hallucinations. Additionally, the patient noted developing urinary incontinence, and worsening gait steadiness with recurrent falls. The patient then developed sleep-wake inversion during the three weeks prior to his fall, and an outpatient referral to neurology was subsequently sent for dementia evaluation. On the night prior to his presentation, the patient took his usual nighttime zolpidem at 22:00 and later fell and was unable to get up. Subsequent testing was negative for reversible causes of dementia and MRI Brain revealed only chronic microvascular disease. His zolpidem dose was decreased to 5 mg and scheduled earlier which resulted in the resolution of his hallucinations, gait abnormalities, and acute encephalopathy. Conclusion One month later, the patient presented to the hospital after a repeat fall secondary to taking his zolpidem at his previously scheduled time. Once more, his dosage was further decreased to 2.5 mg and scheduling earlier, resulting again, in the complete resolution of his symptoms. Zolpidem, has an increased potential for delirium in elderly patients and especially those with dementia. Chronic use of zolpidem with insidiously progressive vascular dementia led to a worsening delirium which resolved after adjustment of timing and reduction of zolpidem dosing. Support (if any):

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“organic Personality Disorder” as Part of Early Neuropsychiatric Manifestations in Huntington’s Disease - a Case Report

European Psychiatry ◽

10.1016/s0924-9338(09)71313-6 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

J. Maia

Keyword(s):

Huntington's Disease ◽

Huntington’S Disease ◽

Psychiatric Symptoms ◽

Age Of Onset ◽

Neuropsychiatric Symptoms ◽

Personality Change ◽

Psychotic Symptoms ◽

Autosomal Dominant Disorder ◽

Neuropsychiatric Manifestations ◽

Psychiatric Manifestations

Huntington's Disease (HD) is an inherited autosomal dominant disorder characterized by motor, cognitive and psychiatric symptomatology, being considered a paradigmatic neuropsychiatric disorder that includes all three components of the "Triadic Syndromes": dyskinesia, dementia and depression.Firstly described in 1872 as an "Hereditary Chorea" by George Huntington only in 1993 was its responsible gene identified. A person who inherits the HD gene will sooner or later develop the disease. the age of onset, early signs and rate of disease progression vary greatly from person to person.Neuropsychiatric symptoms are an integral part of HD and have been considered the earliest markers of the disease, presenting sometimes more than 10 years before a formal diagnosis is done. Patients may experience dysphoria, mood swings, agitation, irritability, hostile outbursts, psychotic symptoms and deep bouts of depression with suicidal ideation. Personality change is reported in 48% of the cases, with the paranoid subtype being described as the most prevalent. the clinical case presented illustrates a case of HD which started with insidious psychiatric symptoms and an important personality change.Despite a wide number of medications being prescribed to help control emotional, movement and behaviour problems, there is still no treatment to stop or reverse the course of the disease. Furthermore, psychiatric manifestations are often amenable to treatment, and relief of these symptoms may provide significant improvement in patient's and caregivers quality of life.A greater awarness of psychiatric manifestations of HD is essential to an earlier diagnosis and an optimized therapeutic approach.

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Psychiatric Symptomatology in Early-Onset Binswanger’s Disease: Two Case Reports

Behavioural Neurology ◽

10.1155/1995/985690 ◽

1995 ◽

Vol 8 (1) ◽

pp. 43-46 ◽

Cited By ~ 2

Author(s):

R. M. Lawrence ◽

J. C. Hillam

Keyword(s):

Early Identification ◽

Psychiatric Illness ◽

Case Reports ◽

Accurate Diagnosis ◽

Psychotic Symptoms ◽

Psychiatric Symptomatology ◽

Neurological Signs ◽

Binswanger’S Disease ◽

History Of ◽

Binswanger's Disease

We describe two cases of Binswanger's disease of pre-senile onset which presented with affective and psychotic symptoms well before the appearance of cognitive deterioration and neurological signs, initially evading an accurate diagnosis. Psychiatrists should be aware of white matter disease and its role in the pathogenesis of psychiatric illness. Particular attention should be given to a history of hypertension as a risk factor in the early identification of these cases.

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MON-252 Pituitary Tumor Apoplexy Presenting with Acute Psychosis

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1517 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Maria Mercedes Pineyro ◽

Patrica Agüero ◽

Florencia Irazusta ◽

Claudia Brun ◽

Paula Duarte ◽

...

Keyword(s):

Psychiatric Disorders ◽

Pituitary Tumor ◽

Psychiatric Treatment ◽

Psychiatric Symptoms ◽

Mental Illnesses ◽

Psychotic Symptoms ◽

Acute Psychosis ◽

Sellar Mass ◽

History Of ◽

Pituitary Tumor Apoplexy

Abstract Background: Pituitary tumors (PT) can present with neuropsychiatric symptoms. It has been associated with hormonal changes, as well as extension of the tumor to the diencephalon. Psychopathology has been reported in up to 83% in Cushing Disease (CD) and 35% in acromegaly (ACR). Psychiatric disorders (depression, anxiety and psychosis) have been reported up to 77% in CD and 63% in ACR. We present a rare case of a patient presenting with acute psychosis and a PT apoplexy. Case: A 27 year-old Caucasian female with a PMH of primary hypothyroidism presented with a 15-day history of delusions. She had delusional ideas on the subject of harm and prejudice, persecutory and mystical-religious. The mechanism was mainly intuitive and interpretive with false acknowledgments. She also had sleep disturbance, death ideation and subacute alteration of consciousness. There was no history of substance abuse or psychiatric disorders. She did not report headaches, visual disturbances, symptoms of hormone hypersecretion or hypopituitarism. She had regular menses on BCP. She had no family history of mental illnesses. Physical exam revealed reluctance, latency in responses and bradypsychia. She did not have acromegalic or cushingoid features. She was diagnosed with acute psychosis with atypical features so a brain CT was performed, which showed a sellar mass. Pituitary MRI revealed a sellar mass measuring 15x12x13 mm, with suprasellar extension, optic chiasm compression, hyperintense on T1- and hypointense on T2-weighted imaging compatible with subacute hemorrhage. She was treated with neuroleptics and benzodiazepines. Lab work revealed high prolactin (PRL) (114ng/dl), and normal 8 AM cortisol, FT4, LH, FSH and IGF-1 levels. Repeated PRL was 31,6 ng/dl after changing psychiatric treatment to aripiprazole. Her psychiatric symptoms improved. We postulate a diagnosis of PT apoplexy that presented with acute psychosis. In relation to the nature of the PT we postulate a non functioning pituitary adenoma (NFA) or a partial resolution of a prolactinoma after apoplexy. A follow up MRI is pending. Discussion: Infrequently, psychiatric symptoms may be the primary manifestation of brain tumors. Patients with PT have been reported to have altered quality of life, reduced coping strategies, increased prevalence of psychopathological alterations and maladaptive personality disorders. In addition, they can present with psychotic symptoms, mostly reported with hormone excess (GH and cortisol). Psychiatric symptoms such as anxiety and neurosis have been reported in NFA and prolactinomas. However, it is not clear a higher prevalence of psychiatric illnesses in these tumors. To our knowledge this is the first case of a pituitary tumor apoplexy presenting with acute psychosis. Conclusion: Psychiatric symptoms can be the first manifestation of PT, so atypical presentations should warrant further workup with brain imaging.

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Risk of bipolar disorder and psychotic features in patients initially hospitalised with severe depression

Acta Neuropsychiatrica ◽

10.1017/neu.2014.42 ◽

2014 ◽

Vol 27 (2) ◽

pp. 113-118 ◽

Cited By ~ 9

Author(s):

Kimiya Nakamura ◽

Junichi Iga ◽

Naoki Matsumoto ◽

Tetsuro Ohmori

Keyword(s):

Bipolar Disorder ◽

Severe Depression ◽

Psychotic Symptoms ◽

Primary Disorder ◽

Icd 10 ◽

History Of ◽

Physical Diseases ◽

The Stability ◽

Psychotic Features ◽

Depressive Episodes

ObjectiveSevere depression may be a risk factor for diagnostic conversion into bipolar disorder (BD), and psychotic depression (PD) has been consistently associated with BD. The aims of the present study were to investigate the stability of the diagnosis of severe depression and the differences between PD and non-psychotic severe depression (non-PD), as well as to assess the effectiveness of electroconvulsive therapy (ECT).MethodsPatients who were hospitalised for severe depression (diagnosed according to ICD-10) both with and without psychotic symptoms (n=89; mean age=55.6 years, SD=13.9) from 2001 to 2010 were retrospectively assessed.ResultsBy the 75th month of follow-up assessments, 11(12.4%) patients had developed BD. Among these 11 converters, nine had developed BD within 1 year after admission. Only sub-threshold hypomanic symptoms were significantly related to developing BD. The number of depressive episodes and history of physical diseases were significantly increased in non-PD compared with PD patients, whereas ECT was significantly increased in PD compared with non-PD patients. There was a significant association between length of stay at the hospital and the number of days between admission and ECT.ConclusionSub-threshold hypomanic symptoms may represent a prodrome of BD or an indicator of an already manifest phenotype, especially in older patients, which suggests cautious use of antidepressants. In severe depression, non-PD may often occur secondary to physical diseases and patients may experience increased recurrences compared with PD patients, which may be a more ‘primary’ disorder and often requires ECT treatments. ECT is effective for severe depression regardless of the presence of any psychotic feature; the earlier ECT is introduced, the better the expected treatment outcome.

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A Case Report of Non-Reactive Psychosis in a COVID-19 Patient

RECENT ADVANCES IN PATHOLOGY AND LABORATORY MEDICINE ◽

10.24321/2454.8642.202104 ◽

2021 ◽

Vol 7 (1&2) ◽

pp. 11-13

Author(s):

Manjulika Debnath ◽

Keyword(s):

Family History ◽

Clinical Presentation ◽

Psychiatric Symptoms ◽

Past History ◽

Psychotic Symptoms ◽

Antigen Test ◽

First Onset ◽

History Of ◽

Coronavirus Infection ◽

Anxiety Depression

Background: COVID-19 causes reactive psychiatric symptoms like anxiety, depression, insomnia etc besides significant inflammatory response. A number of COVID-19 patients are found to present with complex neuropsychiatric syndromes, including the first onset of psychosis, that seem to be directly related to brain damage in the context of COVID-19. Most cases of psychotic disorder in COVID-19 patients are being found in individuals with no personal or family history of mental illness. Case Description: A 33-year-old man presented with acute restlessness, agitation, wandering, vandalizing things, suspiciousness, hallucinatory behaviour, decreased sleep for 3 days duration. There was no past history or family history of any psychiatric illness. There was a history of mild grade fever 7 days before the onset of the psychotic symptoms. The patient was uncooperative, irritable, and had hallucinatory behaviour. Rapid Antigen Test (RAT) was positive. The patient responded to injectable antipsychotic haloperidol which was later changed to Tab Olanzepine 5 mg. The patient developed no COVID symptoms and no psychotic symptoms were seen further. Conclusion: There is a possibility of a psychosis break as a COVID-19 clinical presentation, suggesting potential participation of inflammatory and autoimmunologic phenomena triggered as a response to the coronavirus infection.

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Trials and tribulations of diagnosing and managing psychosis secondary to non-convulsive epilepsy

BJPsych Open ◽

10.1192/bjo.2021.334 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S114-S114

Author(s):

Mahmoud Awara ◽

Joshua Smalley ◽

Matt Havenga ◽

Manal Elnenaei

Keyword(s):

Seizure Activity ◽

Epileptic Activity ◽

Psychotic Symptoms ◽

Visual Hallucinations ◽

Divalproex Sodium ◽

Extensive Investigation ◽

Treatment Resistant ◽

Organic Psychosis ◽

Course Of Illness ◽

History Of

ObjectiveTo highlight the importance of reviewing diagnosis and management of refractory psychosis and to share that with the scientific community; and to also shed some light on the dilemma and challenges that professionals may face to diagnose and treat organic psychosis. In addition, to look at the possible similarity/dissimilarity in psychopathology between organic and primary psychosis and differences in opinions through presenting the history and course of illness of this patient.Case reportWe present the case of a 51-year-old female who had a 28-year history of treatment-resistant schizophrenia. She did not report or display any seizure activity, and an extensive investigation was unremarkable. The unusual nature of her psychopathology, which was predominantly visual hallucinations and somatic delusions, and the difficult to treat nature of her symptoms, prompted investigation with Electroencephalograph which demonstrated bilateral temporal lobe epileptic activity.DiscussionTreatment with divalproex sodium and discontinuation of antipsychotic medication achieved an excellent response, where her visual hallucinations and somatic delusions were both remarkably ameliorated.ConclusionThe differentiation between organic/secondary and functional/primary psychosis is an area of contention between psychiatrists and neurologists and also within each of these specialties.The myriad of psychopathology and associated treatment resistant psychotic symptoms that patients with non-convulsive epilepsy may experience should result in building a long desired bridge between neurology and psychiatry to collaborate in managing such cases.

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Meditation-induced psychosis: a narrative review and individual patient data analysis

Irish Journal of Psychological Medicine ◽

10.1017/ipm.2019.47 ◽

2019 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Pawan Sharma ◽

Ananya Mahapatra ◽

Rishab Gupta

Keyword(s):

English Language ◽

Psychotic Disorders ◽

Case Reports ◽

Psychotic Symptoms ◽

Clinical Settings ◽

Equal Distribution ◽

Meditative Practice ◽

History Of ◽

Age Range ◽

The Relationship

Background: Meditation is associated with health benefits; however, there are reports that it may trigger or exacerbate psychotic states. In this review, we aim to collate case reports of psychotic disorders occurring in association with meditative practice and to discuss the relationship between psychosis and meditation. Methodology: We performed case-based analysis of all the existing studies published in English language using PubMed, PsycINFO, Cochrane, Scopus, EMBASE, CINAHL and Google Scholar with the search terms; ‘Psychosis’ OR ‘Psychotic Symptoms’ OR ‘Schizophrenia’ AND ‘Meditation.’ Results: A total of 19 studies and 28 cases were included in the review. The patients described had an age range of 18–57 years; there was equal distribution of males and females. The diagnoses included acute psychosis in 14 cases, schizophrenia in 7 cases, mania with psychotic symptoms in 3 cases, and schizoaffective disorder in 1 case. The types of meditation described were Transcendent, Mindfulness, Buddhist Meditation like Qigong, Zen, and Theraveda, and others like Bikram yoga, Pranic Healing, and Hindustan Type meditation. Of the 28 cases reported, 14 patients had certain precipitating factors like insomnia, lack of food intake, history of mental illness, stress, and psychoactive substance use. Conclusion: There are case reports of psychotic disorder arising in association with meditative practice; however, it is difficult to attribute a causal relationship between the two. At the same time, there is a body of research describing the beneficial effect of meditative practice in clinical settings for patients with psychotic disorders. Appropriately designed studies are needed to further investigate the relationship between meditative practice and psychosis.

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Psychiatric Symptomatology as the Initial Presentation of Brain Cancer

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.2047 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S165-S165

Author(s):

A. Fornelos ◽

P. Macedo ◽

A. Figueiredo ◽

M. Roque

Keyword(s):

Psychiatric Symptoms ◽

Neurological Diseases ◽

Mass Effect ◽

Adult Brain ◽

Neurological Deficits ◽

Psychotic Symptoms ◽

Social Maladjustment ◽

Organic Brain Disease ◽

History Of ◽

Competing Interest

Glioblastoma multiforme is the most common primary adult brain tumor. Clinically, non-specific psychiatric symptoms may arise as their first and only manifestation, prior to any neurological deficits. The most form of psychiatric presentation of neurological diseases are depressive complaints, although these may also be accompanied by behavioral and/or cognitive, anxious and psychotic symptoms. By explaining this case report we aim to emphasize the importance of considering the diagnosis of an organic brain disease, even when only primary psychiatric symptoms are evident. The bibliographic research was made using PubMed and Scielo, and analysis of the electronic patient process. Man of 68 years with a history of hypertension, nephrectomy, splenectomy and left brachial plegia after a car accident. He had been previously seen by a psychiatrist for a 6-month history of depressive symptoms, which had been successfully treated. He later developed new behavioral changes such as heteroaggressiveness, social maladjustment and disfasia, for which he was sent to the emergency room. Brain-CT scan displayed a left front temporal expansive injury. Admitted to the Neurology Department for further diagnostic investigation. Subsequent MRI, detected massive infiltrative lesion with significant mass effect and cystic/necrotic area. The anatomopathology disclosed a glioblastoma grade IV. This case reinforces the importance of carrying a imagiologic workup in cases like this, especially on patients with atypical presentation of psychiatric symptoms.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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