Investigation of coagulation behavior using Rotational Thromboelastometry (Rotem®) in patients with neuroinfectious diseases

Abstract

Background: European tick-borne encephalitis (TBE) commonly presents with neurological disturbances, whereas primary psychiatric manifestations are rare. Aim: To report a case of acute TBE presenting as major depressive episode. Case report: A 72-year-old man had been suffering from fatigue, poor appetite and tremor of the left hand for 2 weeks. Progression of these symptoms made him believe that he had acquired an incurable and fatal disorder. He repeatedly noted in his diary that 'the end is not far off”. Generalized weakness and fluctuating level of consciousness lead to examination at the Neurologic Department. His psychiatric medical history was unremarkable. Brain MRI, EEG and laboratory examination was normal. Diminished drive, dysthymia, hopelessness and suicidal ideation were found on mental state exam. Diagnosed with major depression he was hospitalized in the psychiatric ward. One day later, he developed a generalized seizure and lab findings supported the diagnosis of European TBE (CSF: 13 cells/μL; protein 60 mg/dL; positive TBE-IgM in serum and CSF). Depressive symptoms declined gradually with a combination of psychotherapy, mirtazapin and sertralin. The tremor responded well to propanolol and was seen as unrelated to TBE. He was discharged home 30 days from admission with minimal residual fatigue and low dose mirtazapin. Conclusion Acute life-threatening psychiatric manifestations can be the predominant presenting but successfully treatable feature of TBE. We conclude that awareness for this condition should be raised in endemic regions and high-level of suspicion for encephalitis maintained with the occurrence of seizures or focal-neurological deficits in acute psychiatric conditions.