Acute Onset Of Confusion Research Articles

A case of clozapine intoxication presenting with atypical NMS symptoms

Clozapine is an antipsychotic drug indicated for treatment-resistant schizophrenia. Clozapine at toxic doses may cause hyperthermia, alterations in consciousness, seizures, cardiac arrhythmias, excessive mucus production in bronchi, hypersalivation, miosis, blood dyscrasias, pancreatitis and hepatitis (Sartorius et al., 2002). Clozapine blood levels are influenced by age, gender, ethnicity, physical illnesses like liver failure, changes in the activity of the cytochrome oxidase enzymes due to genetic variability, concurrent medication use, smoking or caffeine consumption (Greenwood-Smith et al., 2003). Generally, plasma levels of over 1000 ng/ml are associated with central nervous system adverse effects (Varma et al., 2011). One potentially lethal side effect of antipsychotics including clozapine is neuroleptic malignant syndrome (NMS). Neuroleptic malignant syndrome is typically characterized by fever, altered mental status, leukocytosis, autonomic dysfunction and rigidity. Atypical antipsychotics including clozapine are associated less with NMS than typical antipsychotics, and when NMS occurs during treatment with atypical antipsychotics, associated symptoms are less typical (Trollor et al., 2012). In this case report, we present a patient using clozapine for treatment of schizophrenia who was admitted to the Emergency Room with NMS-like symptoms. We present a 53 yr old, female patient diagnosed with schizophrenia, who was on clozapine 500 mg/d for the past 3 yr. She had hyperlipidemia and chronic obstructive pulmonary disease (COPD) and was using rosuvastatin 20 mg/d. She was admitted to the Emergency Room (ER) with acute onset-confusion, shivering, meaningless talk and urinary incontinence. Her body temperature was 39.2°C, blood pressure 90/50 mmHg, pulse rate 117/min, RR: 17/min, SaO2:%96. Electrocardiogram (ECG) was normal. Her Glasgow Coma Score was 15. Blood tests showed hyponatremia (133.2 mEq/l), increased levels of creatinine (1.52 mg/dl), BUN (23.68 mg/dl), uric acid (7.07 mg/dl) and decreased levels of phosphorus (2.50 mg/dl). Liver and thyroid function tests and potassium, chloride and calcium levels were within normal range. Complete …

Angiographic thrombectomy in venous sinus thrombosis: Case review and series

A 61-year-old man with a weeklong occipital headache and acute onset confusion, dysphasia, and vomiting presented to the Emergency department. Plain CT scan of head was suggestive of venous sinus /INS;and cerebral deep venous thrombosis, a finding confirmed on CT Venogram. Following anticoagulation with low molecular weight heparin he experienced a sudden reduction of level of consciousness. Repeat CT scan of head revealed a large right occipital and a smaller left tempo/INS;roparietal haemorrhage.

Teaching Neuro Images : Perfusion imaging of cerebral hyperperfusion syndrome following revascularization

A 69-year-old man developed acute-onset confusion and hypertension with systolic pressures in the 160s 1 day after carotid endarterectomy for right facial droop from left hemispheric lacunar infarcts. CT perfusion (figure, A-D) demonstrated findings consistent with cerebral hyperperfusion syndrome (CHS) following revascularization. CHS is caused by loss of autoregulation, hypertension, and ischemia-reperfusion injury resulting in increased regional blood flow and vascular congestion.(1) CHS following revascularization may present as ipsilateral headache, focal seizure, or neurologic deficit. Nonperfusion imaging may show intraparenchymal hemorrhage or edema. Labetalol and clonidine are used for aggressive blood pressure control until cerebral autoregulation is restored.(2.)

Massive Interventricular Septal Aneurysm and Stroke in a Healthy Young Patient: Guilt by Association?

Aneurysm of the membranous interventricular septum is an uncommon cardiac defect that is, on rare occasions, associated with embolic stroke. We describe here the case of an otherwise healthy, 41-year-old man who presented to the hospital with acute-onset confusion and left-sided body weakness attributed to a right middle cerebral artery ischemic stroke. He experienced a nearly complete resolution of deficits following systemic thrombolytic therapy. After an extensive workup, the presumed mechanism of stroke was a thromboembolus that originated in a massive aneurysm of the patient's membranous interventricular septum. Due to a perceived risk of surgical morbidity, the patient was managed conservatively with anticoagulation. He denied further events and reported nearly full function at follow-up.

Primary leptomeningeal plasmablastic lymphoma

Lymphomas that develop in human immunodeficiency virus (HIV) infected patients are predominantly aggressive B-cells lymphomas. The most common HIV-associated lymphomas include Burkitt lymphoma, diffuse large B-cell lymphoma (that often involves the CNS), primary effusion lymphoma, and plasmablastic lymphoma (PBL). Of these, PBL is relatively uncommon and displays a distinct affinity for presentation in the oral cavity. In this manuscript we report a previously undescribed primary leptomeningeal form of PBL in a patient with acquired immunodeficiency syndrome. A 40-year-old HIV positive man presented with acute onset confusion, emesis, and altered mental status. Lumbar puncture showed numerous nucleated cells with atypical plasmocyte predominance. CSF flowcytometry showed kappa restriction with CD8 and CD38 positivity and negative lymphocyte markers, while the MRI showed diffuse leptomeningeal enhancement. As the extensive systemic work-up failed to reveal any disease outside the brain, an en bloc diagnostic brain and meningeal biopsy was performed. The biopsy specimen showed sheets of plasmacytoid cells with one or more large nuclei, prominent nuclear chromatin, scattered mitoses, and abundant cytoplasm, highly suggestive of plasmablastic lymphoma. HIV-associated malignancies have protean and often confusing presentations, which pose diagnostic difficulties posed to the practicing neurological-surgeons. Even in cases where an infectious cause is suspected for the meningeal enhancement, neoplastic involvement should be considered, and cytology and flow-cytometry should be routinely ordered on the CSF samples.

A 41-Year-Old Man With New Headache and Altered Mental Status

A 41-Year-Old Man With New Headache and Altered Mental Status

Topiramate-induced confusion following a single ingestion of 400 mg

Background Topiramate is an anticonvulsant medication commonly used for a variety of neurological disorders including migraine prophylaxis. Broadened use of topiramate has brought an increased awareness of toxicity from this medication, particularly central nervous system side effects and metabolic acidosis. Objective We describe a case of topiramate toxicity occurring in a 22-year-old female following the ingestion of two 200 mg tablets, which she was prescribed for the treatment of migraines. Results During her outpatient cardiology evaluation for suspected postural orthostatic tachycardia syndrome (POTS), the patient experienced flushing and anxiety. Upon transfer to our hospital she was tachycardic, hypertensive, and confused. Her autonomic symptoms were consistent with her prior episodes of autonomic instability, while the confusion was new. Admission laboratory values revealed a metabolic acidosis with a mildly elevated anion gap. A blood topiramate level returned a value of 8.4 mg/L 15 h after the ingestion. Her symptoms cleared within 24 h following admission. Conclusion Clinicians should consider topiramate toxicity in their differential diagnosis for patients with neurological diseases presenting with acute-onset confusion and metabolic acidosis.

Atypical MRI Findings of Synchronous Cerebral Metastasis

Intracranial metastases represent 7% to 17% of all brain tumors. Metastases may appear before, after or synchronously with the primary tumor. Synchronous tumor presentation means that that metastasis is found within two months of primary tumor diagnosis. A 60-year-old man was seen 15 days after the acute onset of confusion and gait disturbance. Results of a neurologic examination revealed disorientation, dysarthria, and left-sided ataxia. Results of nonenhanced computed tomography scanning of the brain were unremarkable. Cerebral magnetic resonance imaging showed multiple miliary, round, small (maximum diameter, 1 cm) lesions located infra- and supratentorially. Gradient-echo magnetic resonance images of these lesions were compatible with hemorrhage and were more pronounced compared with other sequences. Hemorrhagic cerebral metastases were suspected, and the patient was examined for primary tumors. Chest computerized tomography revealed a tumor in the posterior, superior lobe of the right lung; a cervical lymph node biopsy suggested a metastatic carcinoma. Our case illustrates that magnetic resonance imaging findings of synchronous cerebral multiple metastases presenting with neurologic symptoms may be atypical while the results of cerebral computerized tomography are normal. Contrast-enhanced cerebral magnetic resonance imaging, especially gradient-echo magnetic resonance sequences, should always be considered for diagnosing hemorrhagic metastases in patients presenting neurologic findings with a known or unknown cancer.

Acute confusional state caused by Hashimoto's encephalopathy in a patient with hypothyroidism: a case report

IntroductionHashimoto's Encephalopathy is an unusual condition associated with Hashimoto's Thyroiditis. This immune-mediated, steroid-dependent entity was first described thirty years ago. In this case report, we discuss the importance of considering this diagnosis in the evaluation of confusion.Case presentationThe patient is a 55-year-old African-American woman residing in United States, who was admitted to the hospital with a four-day history of mental status changes. Her past medical history was significant for type II Diabetes Mellitus, Hypertension, and Hypothyroidism. There was no reported seizure activity. The patient's vital signs were stable on admission. On examination, the patient was awake, alert, oriented to place and time. Her neurological examination revealed agraphia and dyslexia. Her speech showed lack of fluency and hesitation. Her complete blood count and electrolytes were within normal limits. The patient's brain CT scan did not reveal any significant findings. Her Magnetic Resonance Imaging only revealed mild chronic microangiopathy, which caused by “small vessel disease.” Her Electroencephalogram did not reveal any finding consistent with seizure activity. Cerebral spinal fluid analysis was likewise did not reveal a cause for this patient's acute onset of confusion. In contrast to the above negative finding, this patient's Thyroid stimulating hormone was discovered to be 15 UIU/ml. She was subsequently given 1000 mg of intravenous Methylprednisolone daily for 3 days. This three-day course of high-dose, intravenous steroids resulted complete resolution of the patient's symptoms. She was then discharged on an eleven-day course of oral prednisone 60 mg.ConclusionHashimoto's Encephalopathy should be considered in the differential diagnosis of an acute confusional state since it is responsive to steroid therapy and represents a readily reversible cause acute mental status changes. Clues to this diagnosis include elevated antithyroid antibodies, abnormal Thyroid stimulating hormone values, and exclusion of other causes of acute mental status changes.

Unusual presentation of basilar artery stroke secondary to patent foramen ovale: a case report

IntroductionWe report a case of a patient presenting with neuropsychiatric manifestations secondary to paradoxical embolismCase presentationUnexplained rapid onset of confusion with amnesia and minimal neurological deficits can be a manifestation of various systemic causes of which stroke, either ischemic or hemorrhagic, is one. Thorough and systematic evaluation of these patients can be highly rewarding in terms of optimizing patient outcome. We report the case of a 45-year-old woman whose initial presentation was with acute onset of confusion, memory loss with personality change and headaches. A differential diagnosis of systemic illness and cerebral pathology was entertained. She was empirically treated for neurological infection. Brain imaging revealed bilateral thalamic and cerebellar infarction. Further evaluation with an aim to define the etiology, revealed the diagnosis of Patent Foramen Ovale with paradoxical embolism. The differential diagnosis of unexplained rapid onset of confusion, amnesia with minimal motor neurological deficits and relevant appropriate investigations are discussed in this case report.ConclusionThis case highlights the importance of recognising the atypical manifestations of posterior fossa stroke. In young patients presenting with non-focal neuropsychiatric manifestations, paradoxical embolism, secondary to patent foramen ovale is a possible cause.

Acute Limbic Encephalitis: Diagnostic and Management Implications

A link between cancer and limbic encephalitis (LE) has been proposed. The aim of this case presentation is to further explore this association by literature review, inform clinicians of the investigations necessary to arrive at a diagnosis and to emphasize the clinical importance of liaison between psychiatry and other disciplines involved in management. The case report of a 55 year old Niuean male school teacher with an acute onset of confusion and personality change is presented. The clinical data was obtained from various sources including the emergency room, medical ward, psychiatric ward as well as from discussions with other physicians involved in the management of this case. Family members and friends were also contacted to obtain corroborative historical information. LE was diagnosed in this case based on clinical presentation with psychiatric symptoms, ruling out delirium due to infections, metabolic and other toxins as well as magnetic resonance imaging findings confirming temporal lobe changes. LE is a known paraneoplastic syndrome (PNS) that may precede the diagnosis of an underlying malignancy. Recent advances in laboratory technology now allow for antibodies to be identified in specific malignancies. This behooves the clinicians to maintain a high level of diagnostic suspicion so that timely interventions with oncology can follow.

Different clinical manifestations of hyperammonemic encephalopathy

Valproate is an effective anticonvulsant. Although it is usually well tolerated, it has been associated with many neurological, hematopoietic, hepatic, and digestive system side effects. Among these side effects, hyperammonemia without clinical or laboratory evidence of hepatotoxicity is rare and is an important clinical consideration. The aim of this article was to evaluate the reasons for the unexpected symptoms observed in seven patients with epilepsy patients during valproate treatment. We evaluated seven adult patients with localization-related epilepsy who presented with different acute or subacute neurological symptoms related to valproate-induced hyperammonemic encephalopathy. Four of the seven patients had acute onset of confusion, decline in cognitive abilities, and ataxia. Two had subacute clinical symptoms, and the other patient had symptoms similar to those of acute toxicity. These unusual clinical symptoms and similar cases had not been reported in the literature before. Serum ammonia levels were elevated in all seven patients. After discontinuation of valproate, complete clinical improvement was observed within 5–10 days. On the basis of our work, we suggest that the ammonia levels of a patient who has new neurological symptoms and has been taking valproate must be checked. Clinicians should be aware that these clinical symptoms may be related to valproate-induced hyperammonemic encephalopathy. The symptoms have been observed to resolve dramatically after withdrawal of the drug.

61-Year-Old Woman With Knee Pain and Confusion

61-Year-Old Woman With Knee Pain and Confusion

Coexistence of Marchiafava–Bignami disease, Wernicke encephalopathy and central pontine myelinolysis in a patient with chronic alcoholism

We reported a 59-year-old man with a history of chronic alcoholism who presented with acute onset of confusion, dysarthria and ataxia. Magnetic resonance imaging (MRI) showed typical features of Marchiafava–Bignami disease, Wernicke encephalopathy, central pontine myelinolysis with mamillary bodies atrophy, extensive lesions involving the corpus callosum, periaqueductal gray matter and central pons. Diffusion-weighted images displayed restricted diffusion in the corpus callosum. These disease entities were rare; all had strong association with alcoholism. His clinical conditions improved dramatically after thiamine supplement. Although coexistence of these entities had been reported, we believe that this is the first report demonstrating the imaging features of these entities in the same patient on MRI.