Neuroleptic Malignant Syndrome in an Elderly Patient with Bipolar Disorder

Neuroleptic malignant syndrome (NMS) is a well-known and potentially fatal complication of antipsychotic use. The elderly population, with multiple risk factors, are more vulnerable to this condition. We described a case of an 80-yearold man with bipolar disorder, previously on oral extended-release sodium valproate, aripiprazole and long-acting injectable paliperidone, who developed NMS. He presented with generalised muscle rigidity, fever, fluctuating blood pressure and elevated creatinine kinase during his hospitalisation for a manic episode. Contributing factors included old age, underlying vascular Parkinsonism, electrolyte imbalance, intercurrent lung infection with acute exacerbation of chronic obstructive pulmonary disease, hyperactive delirium, and repeated administration of parenteral typical antipsychotic. Antipsychotics were withheld promptly, and the patient was treated with dantrolene, bromocriptine and amantadine. His symptoms resolved after a week. He subsequently remained well with oral extended-release sodium valproate alone. Relevant clinical points are discussed. Clinical vigilance, close interdisciplinary cooperation, and prompt interventions are keys to successful to management of NMS in elderly patients.

Compulsory and voluntary admissions in comparison: A 9-year long observational study

Background: Few studies, so far, have been specifically designed to highlight the features related to Compulsory Admissions (CA) and Voluntary Admissions (VA) in Italian psychiatric emergency wards. Aims: The main purpose of this observational study was to compare the sociodemographic and clinical characteristics of VA and CA and to explore possible predictors of re-admissions. Methods: During a 6-month Index Period (February, the 1st–July, the 31st 2008) all psychiatric admissions were documented and then followed-up through all available informatic systems for the next 9 years. Results: Out of 390 hospitalizations, 101 (25.9%) were compulsory (CA rate was 2.79 per 10,000 inhabitants per year, mean duration of hospitalizations of 7.33 ± 7.84 days). Diagnoses were recorded for the 325 patients who had been hospitalized during index period: schizophrenic psychoses ([ p = .042], in particular schizophrenia [ p = .027]), manic episode ( p = .044), and delusional disorders ( p = .009) were associated with CA; conversely, the diagnosis of unipolar major depression ( p = .005) and personality disorders ( p = .048) were significantly more frequent in VA. The 325 admitted patients were followed up for 1,801 person-years. No significant differences were found in terms of drop-outs, transferring, and discharge rates, and mortality rates due to both natural causes and suicides. Factors associated with at least one compulsory readmission were younger age and having had a previous CA ( p = .011); conversely having been engaged with psychiatric services for over 1 year prior to index hospitalization was protective for a subsequent CA ( p = .013). Conclusions: After a 40-year old political reform, the current study shows that, in a context of integrated outpatient and inpatient services, engagement with outpatient care may be protective for compulsory rehospitalization.

Acute Mania and Catatonia in a Teenager Successfully Treated with Electroconvulsive Therapy and Diagnosed with Turner Syndrome and Bipolar Disorder

Background. Turner syndrome (TS) is an X-linked chromosomal abnormality with a global prevalence of 1/2000 live-born girls. The physiological symptoms of TS have been thoroughly characterized, but only a few studies have described associated psychiatric symptoms. We report a case of an adolescent girl who presented with acute mania with psychotic features and was successfully treated with electroconvulsive therapy (ECT). She was subsequently diagnosed with bipolar syndrome and TS. Case Presentation. A 17-year-old girl presented to us with manic symptoms, including disorganized speech, auditory hallucinations, and affect lability. Initially, she was treated with antipsychotics and benzodiazepines, whereby the positive affective symptoms declined. However, the psychotic symptoms progressed, and she developed a catatonic state. ECT was started 6 days after admission, with improvement after two treatments. When ECT was tapered after seven sessions, she relapsed, and the treatment was extended to twelve sessions, with successful outcome. Following discharge, she was diagnosed with TS with partial loss on one of the X-chromosomes (46X, del (X)(p21)), which might have contributed to the development of her sudden acute manic episode. Conclusions. This case demonstrates for the first time that ECT may be a safe and efficient treatment strategy for acute mania in adolescents with concomitant TS and that severely affected adolescents may require a prolonged series with gradual tapering of ECT. The present case also demonstrates a possible association between TS and bipolar syndrome and that the clinical presentation of a manic episode in a patient with this comorbidity could be more complex and the treatment response slower.

Neurocysticercosis presenting as bipolar disorder: a case report

Neurocysticercosis is the most common neuro-parasitosis caused by the larval stage of Taenia solium. The most common manifestations include seizures and hydrocephalus. Psychiatric abnormalities are relatively rare but depressive symptoms are frequent in patients with neurocysticercosis. However, mania as a presentation is relatively rare. Pregnancy and the postpartum period are relatively vulnerable times and they can lead to reactivation of existing neurocysterci lesions. We are discussing the case of a 23-year-old female patient with neurocysticercosis leading to the reactivation of lesions in the peripartum and postpartum period leading to bipolar affective disorder. Improvement in the patient was seen with a combination of antipsychotics, antihelmintics, antiepileptics and steroids, along with improved radiological signs of neurocysterci lesions. Although neurocysticercosis is a common illness, its prevalence presenting as a manic episode is merely 2.6% and, hence, missed easily. Therefore, it is important to rule out organic aetiology in patients even with a classic presentation of bipolar affective disorder and those having any other neurological symptoms and signs.

Use of Dantrolene and Ativan to Treat Overlapping Diagnosis NMS Versus Malignant Catatonia Case Report

We present a case report of a patient who developed symptoms resembling malignant catatonia and neuroleptic malignant syndrome. Suspicion of neuroleptic malignant syndrome arose after treatment over his course of hospital stay with three different second-generation antipsychotics for a first-time bipolar type I manic episode. After a hospital stay of 5 days, the patient developed symptoms that could be interpreted as malignant catatonia or neuroleptic malignant syndrome. Administration of antipsychotics was immediately ceased, and the patient was transferred to the ICU where he was treated with dantrolene and higher dosages of Ativan. The patient improved after simultaneous intervention for both possible diagnoses. After approximately one month, quetiapine, one of the second generation antipsychotics previously prescribed, was restarted with good results and no reoccurrence of NMS or malignant catatonia. This case illustrates the potential dilemma faced when differentiation between the two obscure diagnoses is necessary. Diagnosis is typically established through clinical observation and monitoring of symptom evolution after the administration of neuroleptics. The treatment algorithms for each diagnosis vary as can the respective outcomes. Our case also highlights the dearth of research available on distinguishing neuropathologic psychiatric disorders from pathophysiologic psychomotor syndromes. It also focuses on the need for sound diagnostic scoring scales that will clarify the diagnostic picture as well as treatment guidelines to ensure best outcomes.

Comorbidity and Treatment in Older Psychiatric In-patients—A Retrospective Study in a Chinese Psychiatric Hospital

Background: Comorbid somatic diseases increase the death risk and affect the condition, treatment, and prognosis of older psychiatric patients. We investigated the comorbidity and drug treatment in older patients with psychosis.Methods: This retrospective study used data from 3,115 older psychiatric in-patients hospitalized at the Shanghai Mental Health Center Affiliated to Shanghai Jiaotong University School of Medicine, China discharged from 2005 to 2015. Descriptive analyses of patients' age, sex, treatment drugs, diagnoses (based on ICD-10), and time trend were performed.Results: Patients' median age was 56 (range, 50-98) years; 1,824 (58.6%) were female. The top five first-level diagnoses were schizophrenia (F20) (n = 1,818, 58.3%), depressive episode (F32) (n = 457, 14.6%), bipolar affective disorder (F31) (n = 151, 4.8%), manic episode (F30), (n = 143, 4.6%), and vascular dementia (F01) (n = 136, 4.4%). Mental (99.9%), central nervous system (85.2%), digestive system (83.5%), cardiovascular system (72.5%), and anti-infective (59.6%) drugs had the highest prescription rates. The combined use of antidepressants, anti-anxiety, anti-arrhythmic, hormones and endocrine system drugs were significantly higher in female than in male patients, while mood stabilizers and genitourinary system drugs significantly more frequent in men. With increasing age, the F20-F29 patients decreased, while F00-F09 patients increased, with the corresponding changes to prescription in those patients. In comparison to that in 2005-2010, the combined prescriptions for genitourinary and cardiovascular drugs increased between 2011 and 2015, and F00-F09 and F40-F48 older patients doubled, accordingly anti-Alzheimer's disease drugs and antidepressants more than doubled. F30-F39 patients increased by 49.1%, and anti-anxiety drugs, mood stabilizers, etc. increased by ≥50%; F20-F29 older patients decreased by 26.7%, while antipsychotics only increased by 4.4%.Conclusions: This study found the combined drug treatment of somatic diseases, particularly for central nervous, digestive, cardiovascular, respiratory and genitourinary drugs were extremely common among older psychiatric in-patients in China. With increasing age, the F20-F29 patients decreased, while F00-F09 patients increased; the antipsychotics prescriptions decreased, and almost all comorbidity drugs increased. Compared with that in 2005-2010, the older patients with all diagnosis except F20-F29 increased in 2011-2015, and the prescriptions for psychotropic, genitourinary, and cardiovascular drugs increased.

Emergence of the first manic episode in recovered COVID-19 patients: A case series from Egypt

Objective In December 2019, the novel coronavirus (COVID-19) infection was first reported in Wuhan city, China, which had rapidly spread as a global pandemic. This infection was commonly presented by respiratory and /or gastrointestinal symptoms. However, it is still unclear whether COVID-19 infection could be associated with central nervous system (CNS) damage which would result in development of neuropsychiatric symptoms. Method A total of five cases of suddenly emerged manic episodes during the pandemic of COVID-19 were extensively described. We presented the symptoms and described the diagnosis, clinical course, and treatment of each case. Results All patients had positive findings of ribonucleic acid (RNA) tests for COVID-19 in specimens of their sputum. The patients later developed manic symptoms during and after the recovering period of their illness. Conclusions The case series of newly emerged manic symptoms associated with COVID-19 infection highlights the essential need for evaluation of mental health status and would contribute to our understanding of the potential risk of CNS affection by COVID-19 infection. The limited number of cases would limit the generalizability of association. Future research should investigate the behavioral changes accompanying and following COVID-19 infection.