Mental Status Changes Research Articles

A Quality Improvement Strategy to Improve Recognition and Identification of Atypical Stroke Presentations in the Pre-Hospital Setting (P13-2.006)

<h3>Objective:</h3> To improve recognition and identification of atypical stroke presentations by EMS. <h3>Background:</h3> Several stroke prediction scales have been devised to aid emergency medical staff (EMS) and physicians to timely recognize strokes in the prehospital setting. However, a significant proportion of strokes continues to be missed. The most common symptoms in false negative cases are dizziness, changes in mental status, and visual deficits. <h3>Design/Methods:</h3> The curriculum involves a lecture with 5 cases discussing presentations of posterior circulation stroke, that was preceded and followed by a survey. A 3-point Likert scale was utilized to assess comfort levels of EMS. Wilcoxon rank sum tests were performed on the null hypothesis to examine the effect of education on comfort levels as implemented in R (R version 3.5.3). <h3>Results:</h3> Eighty pre- and post-education surveys were included in the analysis. More individuals in the post-lecture group felt comfortable recognizing basilar artery occlusion stroke, stroke syndromes that could present as altered mental status or lethargy/somnolence, and cranial nerve deficits as brainstem stroke presentations compared to individuals in the pre-lecture group (p&lt;0.05). More individuals in the post-lecture group felt comfortable recognizing visual symptoms as stroke presentations compared to individuals in the pre-lecture group though the difference in distributions in the two groups did not differ significantly (W= 2854.4, p=0.08). <h3>Conclusions:</h3> In conclusion, our education strategy highlighted atypical stroke presentations that may be missed using conventional pre-hospital scales and resulted in statistically significant increased comfort levels among EMS abilities to recognize various atypical stroke symptoms. Visual symptoms did not increase significantly which was likely due to high comfort levels among EMS at baseline. This lecture was delivered both in-person and virtually, reflecting ease of our implementation strategy. Future work will evaluate the efficacy of our strategy by comparing acute stroke presentations associated with inaccurate EMS identification before and after intervention in our region. <b>Disclosure:</b> Dr. Reyes has nothing to disclose. Dr. Zobel has nothing to disclose. Dr. Ess has nothing to disclose.

Patient-Reported Outcomes in Myotonic Dystrophy Type 2: Correlations with Motor and Cognitive Endpoints (S7.007)

<h3>Objective:</h3> To characterize patient-reported outcomes (PROs) and evaluate relationships between PROs and clinical endpoints in patients with myotonic dystrophy type 2 (DM2). <h3>Background:</h3> Although muscle weakness is the key feature in DM2, two-thirds of patients report that impaired cognition is among the most disabling symptoms and affects their quality of life. PROs of physical and mental status are extremely limited in DM2 but could serve as measures for clinical trial development. <h3>Design/Methods:</h3> Ten individuals with DM2 and ten age and gender-matched controls were enrolled. All participants underwent brain MRIs and a comprehensive battery of cognitive and motor measures. Additionally, they completed PROs, including the 36-Item Short Form (SF-36), PRO Measurement Information System (PROMIS-10), Beck Depression and Anxiety Inventory (BDI and BAI), and Apathy Evaluation Scale (AES). Paired t-test and Spearman’s correlation were used to determine group differences and correlations between PROs and clinical endpoints. <h3>Results:</h3> Of 20 participants (60% female), mean age and education were similar between groups. Compared to controls, the DM2 group showed a significant difference in BAI, AES, and SF-36 physical functioning (PF) subscale (<i>p</i>=0.004–0.024) and impaired PROMIS-Global Physical (GPH) and Mental Health (GMH). We found a strong correlation between SF-36 (PF) and PROMIS-GPH with a 6-minute walk test and gait speed (<i>rho</i>=0.68–0.75, <i>p</i>=0.02–0.04). Moderate correlations were observed between 1) BDI and verbal fluency test; 2) BAI and processing speed; 3) AES and a test of executive function and cerebral white matter integrity. <h3>Conclusions:</h3> Our pilot study demonstrates that changes in mental and physical health status are of significance for DM2 patient’s quality of life. The relationships between PROs (BAI, BDI, and AES) and cognitive endpoints suggest brain involvement. PROs, as measured by SF-36 and PROMIS-10, are associated with motor endpoints. These results support the use of PROs as a tool to measure disease burden in DM2. <b>Disclosure:</b> Dr. Jain has nothing to disclose. Dr. Olszewski has nothing to disclose. Dr. Flashman has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Archives of Clinical Neuropsychology. The institution of Dr. Flashman has received research support from NIH/NINDS. The institution of Dr. Flashman has received research support from Michael J Fox Foundation. Mrs. Burgos-Aguilar has nothing to disclose. Dr. Duncan has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for BrainQ Technologies. Dr. Duncan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Pittsburg Pepper Center. Dr. Duncan has stock in CareDirections. The institution of Dr. Duncan has received research support from PCORI. The institution of Dr. Duncan has received research support from NIA and NINDS. The institution of Dr. Duncan has received research support from AHRQ. Dr. Duncan has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Nopoulos has received personal compensation in the range of $500-$4,999 for serving as a Consultant for norvartis. The institution of Dr. Puwanant has received research support from Muscular Dystrophy Association. The institution of Dr. Puwanant has received research support from NIH/NINDS. The institution of Dr. Puwanant has received research support from NIH/NINDS.

Bacterial Meningitis in Paediatrics: A Review

Meningitis is a potentially life-threatening condition characterized by infection or inflammation of the central nervous system. It is classified as bacterial, viral, or aseptic. Delayed or untreated bacterial meningitis is associated with high morbidity and mortality. It is important to accurately distinguish between bacterial and nonbacterial meningitis. Most physicians will perform a lumbar puncture and consider antibiotics for all infants and children with suspected meningitis. Having a clinical prediction rule to determine the need for lumbar puncture and which patients need antibiotics could reduce morbidity and the cost associated with unnecessary procedures and treatment. Several clinical prediction rules to determine the risk of bacterial meningitis have been proposed. One clinical prediction rule, derived and validated from cohorts seen in pediatric hospitals in the Netherlands, found that altered consciousness, meningeal irritation, cyanosis, petechiae, vomiting, duration of main symptom, and an elevated C-reactive protein and Erythrocyte Sedimentation Rate level were independent predictors of bacterial meningitis. Patients below a predefined threshold on a risk score incorporating these elements could be safely considered as not having bacterial meningitis. Keywords: Bacteria, Meningitis, petechiae, C - reactive protein, pediatrics, ESR

Non-convulsive status epilepticus possibly induced by a rapid correction of severe hyperkalemia: a case report and literature review

BackgroundPatients with chronic kidney disease frequently develop neurological complications including confusion and altered consciousness. Non-convulsive status epilepticus, which is characterized by a change in behavior and/or mental process accompanied by epileptiform discharges on electroencephalogram in the absence of convulsive seizures, is one of the overlooked causes of altered consciousness. The incidence and precise pathophysiological mechanism of non-convulsive status epilepticus in patients with kidney disease, and especially in patients with electrolyte disturbances, remains unknown. We recently treated an older patient with chronic kidney disease and severe hyperkalemia in whom non-convulsive status epilepticus developed following a correction of severe hyperkalemia.Case presentationAn 82-year-old male was admitted to our hospital at midnight because of weakness of all four limbs (Day 1). He underwent urgent hemodialysis for severe hyperkalemia (9.84 mEq/L) and his serum potassium concentration decreased to 4.97 mEq/L. He regained full consciousness and his limb weakness improved on the morning of Day 2, but he became confused in the evening. Electroencephalogram revealed repeated low-voltage ictal discharges in the right occipital region and a diagnosis of non-convulsive status epilepticus was made. Following medication with fosphenytoin and phenytoin, the patient became fully alert and orientated on Day 8.ConclusionWe speculate that a rapid correction of hyperkalemia was the possible cause of non-convulsive status epilepticus development. To our knowledge, this is the first report of non-convulsive status epilepticus from a potassium abnormality. We described a case of this condition in detail and summarized 78 previous case reports of non-convulsive status epilepticus with kidney disease or electrolyte disturbances.

Autoimmune glial fibrillary acidic protein astrocytopathy associated with breast cancer: a case report

BackgroundAutoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) is an autoimmune inflammatory central nervous system disorder characterized by the detection of autoantibodies that recognize GFAP in CSF. The pathogenesis of GFAP-A is poorly understood. Some patients had a neoplasm detected and GFAP expressed by neoplasms is plausible as immunogen triggering paraneoplastic neurological autoimmunity.Case presentationWe report a case of 76-year-old female patient with GFAP-A complicated with breast cancer. She presented with altered consciousness, nuchal rigidity, speech disturbances, and weakness. Her clinical symptoms were improved by immunotherapy and cancer treatments. Immunohistochemical analysis showed that the restricted tumor expressed GFAP. The infiltration of CD3 + T cells were observed in the peritumoral and intratumoral areas. The most common infiltrating lymphocytes were CD8 + T cells. CD4 + T cells and CD20 + B cells were also observed in the predominant peritumoral area.ConclusionsThese results suggest that GFAP-A may occur in a paraneoplastic neurological syndrome associated with breast cancer.

Isoniazid-induced Encephalopathy in a Patient with Pott’s Disease with Chronic Kidney Disease: A Case Report

We report an isoniazid-induced encephalopathy in a man with chronic renal failure. Drug-induced encephalopathy is a common side effect of many drugs. Isoniazid (INH), a first-line drug for tuberculosis, can cause encephalopathy in patients with chronic kidney disease (CKD). For Pott's disease of the thoracic spine, he received rifampicin, INH, pyrazinamide, and ethambutol with pyridoxine and prednisolone. But the patient is free of pyridoxine for two and a half months. Subsequently, after treatment, the patient experienced recurrent episodes of altered consciousness, irrelevant conversations, and disorientation. After ruling out other causes, isoniazid-induced encephalopathy was suspected and confirmed by improvement of symptoms after discontinuation of high-dose isoniazid and pyridoxine. J Rang Med Col. March 2023; Vol. 8, No. 1:72-75

EEG changes as an indication of central nervous system involvement following cyclopentolate 1% eye drops; a randomized placebo-controlled pilot study in a pediatric population

ABSTRACT To compare EEG-patterns after instillation of cyclopentolate versus placebo eye drops. Prospective, randomized, placebo-controlled, and observational pilot study is presented. Ophthalmology outpatient clinic Dutch metropolitan hospital. Healthy 6- to 15-year-old volunteers with normal or low BMI requiring a cycloplegic refraction/retinoscopy. Randomized; 1 visit 2 drops cyclopentolate-1% and 1 visit 2 drops placebo (saline-0.9%). Single-blind: conducting researcher. Double blind: subjects, parents, clinical-neurophysiology staff, neurologist, and statistician. A 10-min baseline EEG-recording, drop-application, and follow-up to at least 45 min. Primary outcome: Detection of CNS changes, i.e. EEG-pattern changes, following two drops of cyclopentolate-1%. Secondary outcome: Determination of the extent of these pattern changes. Thirty-six cyclopentolate-1% saline-0.9% EEG registrations were made in 33 subjects; 18 males and 15 females. Three subjects were tested twice (interval 7 months). Nine out of fourteen (64%) of the 11- to 15-year-old children reported impaired memory, attention, alertness, as well as mind wandering following cyclopentolate. Drowsiness and sleep were seen in EEG-recordings of 11 subjects (33%) following cyclopentolate. We observed no drowsiness nor sleep during placebo recordings. The mean time to drowsiness was 23 min. Nine subjects arrived in stage-3 sleep but none arrived in REM-sleep. In subjects without sleep (N=24), significant changes compared to placebo-EEG were present for many leads and parameters. The main findings during awake eye-open recording were as follows: 1) a significant increase of temporal Beta-1,2 and 3-power, and 2) a significant decrease in: a) the parietal and occipital Alpha-2-power, b) the frontal Delta-1-power, c) the frontal total power, and d) the occipital and parietal activation synchrony index. The former finding reflects cyclopentolate uptake in the CNS, and the latter findings provide evidence for CNS suppression. Cyclopentolate-1% eye drops can affect the CNS and may cause altered consciousness, drowsiness, and sleep with concomitant EEG results in both young children and children in puberty. There is evidence that cyclopentolate has the potency to act as a short acting CNS depressant. Nevertheless, however, cyclopentolate-1% can safely be used in children and young adolescents.

Bilateral medial medullary infarction due to varicella‐zoster virus vasculopathy: A case report

AbstractBilateral medial medullary infarction (MMI) is a rare form of ischemic stroke, mainly caused by vertebral artery atherosclerosis or small penetrating artery disease. We report a case of bilateral MMI due to varicella‐zoster virus (VZV) vasculopathy. An 81‐year‐old man presented with altered consciousness and right hemiplegia during disseminated herpes zoster. Polymerase chain reaction analysis of his cerebrospinal fluid detected positive VZV‐DNA, and magnetic resonance imaging revealed ischemic infarction localized to the ventral part of the bilateral medial medulla and enhancement of the left vertebral artery. After initiating intravenous acyclovir administration, his consciousness, skin rashes, and general condition improved gradually, whereas pyramidal symptoms deteriorated into quadriplegia. This case demonstrates that VZV vasculopathy may cause bilateral MMI.

Post-approval studies with the CFTR modulators Elexacaftor-Tezacaftor-Ivacaftor.

Triple combination therapy with the CFTR modulators elexacaftor (ELX), tezacaftor (TEZ) and ivacaftor (IVA) has been qualified as a game changer in cystic fibrosis (CF). We provide an overview of the body of literature on ELX/TEZ/IVA published between November 2019 and February 2023 after approval by the regulators. Recombinant ELX/TEZ/IVA-bound Phe508del CFTR exhibits a wild type conformation in vitro, but in patient's tissue a CFTR glyoisoform is synthesized that is distinct from the wild type and Phe508del isoforms. ELX/TEZ/IVA therapy improved the quality of life of people with CF in the real-life setting irrespective of their anthropometry and lung function at baseline. ELX/TEZ/IVA improved sinonasal and abdominal disease, lung function and morphology, airway microbiology and the basic defect of impaired epithelial chloride and bicarbonate transport. Pregnancy rates were increasing in women with CF. Side effects of mental status changes deserve particular attention in the future.

Euglycemic Diabetic Ketoacidosis Associated With SGLT2 Inhibitor Therapy: A Case Report.

Sodium-glucose cotransporter-2 inhibitors are now considered second-line treatment agents for type 2 diabetes and offer a unique treatment approach with added cardiorenal benefits. Drugs in this class increase the risk of euglycemic diabetic ketoacidosis, which may be difficult to diagnose if clinicians are not aware of the risk factors and subtle symptoms. This article describes a case of euglycemic diabetic ketoacidosis in a patient with coronary artery disease who was taking a sodium-glucose cotransporter-2 inhibitor and experienced acute mental status changes immediately after heart catheterization.

The Near-Death Experience and Suicidal Ideation.

The near-death experience (NDE) most generally refers to a state of altered consciousness with various features that can occur during real or presumed near-death circumstances and/or life-threatening incidents. Some NDEs are associated with a nonfatal suicide attempt. This paper discusses how a belief by suicide attempters that their NDEs are a true portrayal of objective spiritual reality can at least in some cases be positively associated with a persistence or increase of suicidal ideation and on occasion lead to further suicide attempts, while also exploring why at other times such a belief may reduce the risk of suicide. The formulation of suicidal ideation associated with NDEs among some of those who did not initially try to kill themselves is also explored. Various examples related to NDEs and suicidal ideation are provided and discussed. Furthermore, this paper also offers some theoretical insights related to this matter and points out some specific therapeutic concerns based on this discussion.

Proposal of a Method for Transferring High-Quality Scientific Literature Data to Virtual Patient Cases Using Categorical Data Generated by Bernoulli-Distributed Random Values: Development and Prototypical Implementation

Teaching medicine is a complex task because medical teachers are also involved in clinical practice and research and the availability of cases with rare diseases is very restricted. Automatic creation of virtual patient cases would be a great benefit, saving time and providing a wider choice of virtual patient cases for student training. This study explored whether the medical literature provides usable quantifiable information on rare diseases. The study implemented a computerized method that simulates basic clinical patient cases utilizing probabilities of symptom occurrence for a disease. Medical literature was searched for suitable rare diseases and the required information on the respective probabilities of specific symptoms. We developed a statistical script that delivers basic virtual patient cases with random symptom complexes generated by Bernoulli experiments, according to probabilities reported in the literature. The number of runs and thus the number of patient cases generated are arbitrary. We illustrated the function of our generator with the exemplary diagnosis "brain abscess" with the related symptoms "headache, mental status change, focal neurologic deficit, fever, seizure, nausea and vomiting, nuchal rigidity, and papilledema" and the respective probabilities from the literature. With a growing number of repetitions of the Bernoulli experiment, the relative frequencies of occurrence increasingly converged with the probabilities from the literature. For example, the relative frequency for headache after 10.000 repetitions was 0.7267 and, after rounding, equaled the mean value of the probability range of 0.73 reported in the literature. The same applied to the other symptoms. The medical literature provides specific information on characteristics of rare diseases that can be transferred to probabilities. The results of our computerized method suggest that automated creation of virtual patient cases based on these probabilities is possible. With additional information provided in the literature, an extension of the generator can be implemented in further research.

Rapid onset brain plasticity at novel pharmacologic targets hypothetically drives innovations for rapid onset antidepressant actions.

Numerous new agents with rapid onset antidepressant effects are entering clinical trials and clinical practice. Studies focus on either first-line treatment of major depressive disorder or on patients whose major depressive disorder is resistant to prior antidepressant drugs. Novel agents target three very different central nervous system sites: as antagonists of N-methyl-d-aspartate (NMDA) glutamate receptors, as positive allosteric modulators (PAMs) of gamma amino butyric acid (GABA) A neurosteroid and benzodiazepine receptor sites, and as psychedelic agonists of serotonin 2A/2C receptors. Onset of antidepressant action is rapid, sometimes after only one dose whereas traditional agents for depression take several days to weeks to have an antidepressant effect. Although the direct molecular targets of these three classes of agents with rapid antidepressant onset are quite diverse and not clearly related to each other, analysis of the downstream effects of all these agents show that all are "plastogens," namely agents that trigger rapid onset of neuroplasticity that correlates with their rapid onset of antidepressant clinical action. The GABA A PAMs and some of the NMDA antagonists induce neuroplasticity without notable changes in mental status and can be designated "neuroplastogens." Some NMDA antagonists cause mental dissociation, and the psychedelics cause psychotomimetic/hallucinatory experiences and can be designated "psychoplastogens." A great debate exists whether psychoplastogens are effective because of their ability to acutely alter mental state, or whether these acute mental states are unwanted behavioral toxicity. The promise of numerous novel agents with rapid acting antidepressant action and neuroplasticity is set to transform the treatment of major depressive disorder.

Nosocomial outbreaks of aseptic meningitis: A public health concern

Nosocomial outbreaks of aseptic meningitis: A public health concern

Associations between mental health status and labor force transitions in China: A longitudinal study between agricultural and nonagricultural sectors.

No consensus has been reached on the relationship between retirement and mental health, and limited information is available on retirement and mental health in developing countries. This study investigated the associations between short-term changes in mental health status and labor force transitions (retirement and reemployment) in both the agricultural and nonagricultural sectors in China. This study used nationally representative panel data from three waves (2011, 2015, and 2018) of the China Health and Retirement Longitudinal Study on workers and retirees aged 40-70 years in China. The latent change score (LCS) model was employed. The transition from nonagricultural and agricultural sectors to retirement significantly increased the changes in the Center for Epidemiological Studies-Depression scale (CES-D-10) score. Reentering the nonagricultural sectors significantly decreased the changes in the CES-D-10 score, whereas reentering the agricultural sectors had no impact on the changes in the CES-D-10 score. Stronger associations were identified among male workers, while the associations were weaker and less significant for female workers. Findings are consistent with the resource-based dynamic theory and extends the work in developing country by showing the mental health status worsens after retirement transitions and improves after reentering the workforce, especially for nonagricultural male workers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of Transcranial Direct Current Stimulation on Motor Recovery in Altered Conscious Patients after Traumatic Brain Injury and Cerebrovascular Accident: A Randomized Clinical Trial

Abstract Background and Purpose Altered levels of consciousness resulting from a vascular insult to the brain can vary from confusion to coma. A disruption in the function of the brain stem reticular activating system in the brain stem or both cerebral hemispheres and thalami causes coma. This study is aimed at finding the effect of transcranial direct current stimulation (tDCS) on motor recovery in altered conscious patients after traumatic brain injury and cerebrovascular accident. Materials and Methods A total of 100 patients admitted to the neurology and neurosurgery unit of the university hospital were screened and 40 subjects who satisfied inclusion criteria were recruited and randomly divided into two groups, group A (experimental; n = 20) and group B (control; n = 20), by computerized randomization. Written informed consent was taken from all the caregivers before recruitment. After taking the preliminary assessment, anodal tDCS is given to the motor area (C3/C4 ipsilesional), sensory area (P3/P4 ipsilesional), and left dorsolateral prefrontal cortex (F3) according to the 10/20 electroencephalogram montage for two sessions of 20 min/day for 7 consecutive days. Routine physiotherapy was also given the same as group B. Results At baseline, there were no significant group differences in the baseline characteristics. The groups passed the normality test. The results were tested for statistical significance between the groups by Mann–Whitney U-test and by one-way analysis of variance and Tukey Honest Significant Difference for post-hoc comparison; the results were statistically different with p-value less than 0.05 with a large effect size. Conclusion We conclude, based on the results of this study, that tDCS can be effective in motor recovery in altered consciousness patients. It is noninvasive, cost-effective with minimal contraindications, and does not interfere with other modalities in the intensive care unit. Hence, it can be administered safely under the supervision of a qualified therapist.

Survey study of the etiology of non-traumatic altered consciousness in the Emergency Department at Suez Canal University Hospital in Egypt.

Disorders of consciousness including coma in non-trauma patients can be caused by a wide variety of pathologies affecting the central nervous system. They represent a frequent challenge in emergency medicine and are combined with a very high in-hospital mortality. Hence, early treatment of these patients is vital and increases the likelihood of a good outcome. To identify the causes of altered consciousness presentation to the Emergency Department at Suez Canal University Hospital. This was a descriptive cross-sectional study conducted on 87 patients with acute non-traumatic disturbed level of consciousness (DLOC) at the Emergency Department. The mean age of the studied patients was 60.5 ± 13.6 years. Among them, 60% were males and 40% were females. The most common cause of acute non-traumatic DLOC was systemic infection, such as sepsis and septic shock (25.3%), followed by respiratory causes (24.1%) and neurological causes (18.4%). The most common cause of acute non-traumatic DLOC was systemic infections followed by respiratory and neurological causes.

Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis.

Occlusion of artery of Percheron (AOP), a rare variant of paramedian branches of posterior cerebral artery, results in a characteristic pattern of ischemic lesions in bilateral paramedian thalami with or without midbrain and anterior thalami involvement. To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. We retrospectively search in our stroke center database, patients with ischemic lesions in the AOP distribution. We collected clinical features and time between hospital admission and diagnosis. Imaging findings were categorized following a pre-selected classification. Of 2830 ischemic stroke admitted in our center, we identified 15 patients with AOP infarction (0.53%). Clinical manifestations were variable, but oculomotor disturbances, particularly vertical gaze palsy, were the most observed, followed by consciousness impairment, varying from drowsiness to coma. The most frequent imaging pattern was bilateral paramedian thalamic infarction with midbrain infarction, and the V-sign was recognized in 6 cases from this group. In 8 patients a fetal origin of the PCA was observed. The average time from first hospital admission to diagnosis was 28.09h. The prevalence of AOP infarction in our center was 0.53%. Diagnosis of AOP infarction can be challenging and should be suspected in case of sudden altered consciousness.

The dangers of neuroleptic use in Parkinsonian-spectrum illnesses - management of emergent hypodopaminergic syndromes and catatonia

IntroductionIn Parkinson disease (PD), the incidence of psychotic symptoms has an estimated rate of 25-30%, a cumulative long term prevalence rate of 60%, with visual hallucinations being the most common type of sensory hallucination. The use of high and low potency, antidopaminergic, antipsychotic medications (AP) have the potential to exacerbate motor symptoms of PD and precipitate neuroleptic malignant syndrome (NMS), neuroleptic malignant-like syndrome in PD known as Parkinson hyperpyrexia syndrome (PHS), and catatonia in at risk population. MethodsHere, we present a clinical case and a review of the current treatment modalities available for movement disorder emergencies in parkinsonian-spectrum illnesses (PSI). Patient was assessed by a multidisciplinary team, including neurology and a geriatric consult-liaison psychiatry service. ResultsThis is a case report of a 79-year-old man with no previous psychiatric history, an initial diagnosis of PD due to early emergence of tremors and motor symptoms responsive to levodopa-carbidopa (LC). This was followed by progressive cognitive impairments, delusional jealousy, and formed visual hallucinations, which prompted concern for cortical lewy body involvement. Pimavanserin was initiated for presumed diagnosis of Parkinson disease psychosis and ameliorated the frequency of visual hallucinations. Patient presented to the hospital for agitation and was positive for COVID-19 on admission; prior to this, he had missed doses of LC and was febrile per family. He received intramuscular haloperidol and ziprasidone for behavioral disturbances and subsequently developed delirium, severe VH's, elevated serum CK, diffuse rigidity, and hyperactive non-purposeful activity, raising concern for NMS.Emergent treatment included bromocriptine, lorazepam, and supportive measures; home dose of LC and pimavanserin were resumed after significant reductions in CK levels. Unfortunately, rigidity and delirium persisted leading to a prolonged hospitalization and requirement of a nasogastric tube for malnutrition. Neurology was concerned for PHS due to clinical overlap with NMS. Psychiatry consult-liaison service suspected protracted delirium and catatonia secondary to recent COVID-19 infection and neuroleptic use.Initial Bush Francis Catatonia Rating Score (BFCRS) was 22. Treatment trials of benzodiazepines, amantadine and memantine were unsuccessful due to adverse effects of excessive sedation, myoclonus, and increase aggression, respectively. Ultimately, bilateral, brief wave, electroconvulsive therapy (ECT) was initiated. Patient had improvements in increased alertness, executive speech, verbal comprehension, appetite, with BFCRS 6 by ninth ECT session, and was more attuned to his surroundings. After twelve ECT sessions and successful treatment of catatonia, despite some residual delirium, family felt comfortable caring for patient at their own home with supportive services. ConclusionThis case demonstrates the nebulous presentation of overlapping syndromes of delirium and catatonia - with NMS and PHS also in the differential - in the setting of acute COVID-19 infection and iatrogenic neuroleptic use in a patient with PSI. NMS and catatonia can be precipitated by dopaminergic blockade, while PHS is most encountered during dopaminergic withdrawal and intercurrent infections. Theorized pathophysiology is due to central dopamine hypofunction, leading to clinical features of altered consciousness, fevers, elevated serum CK, and parkinsonian exacerbation – all of which can be indistinguishable from the above-mentioned diagnoses. These syndromic illnesses appear to occur on an NMS-like spectrum, are a neurological emergency and necessitate prompt treatment with supportive measures, intensive care level monitoring, and restoration of the dopaminergic balance with LC, bromocriptine, and dantrolene. ECT has shown to improve both motor and psychotic symptoms in PD, should be first line in NMS, malignant and benzodiazepine-refractory catatonia, and has even demonstrated effectiveness in a case report of PHS. ECT could be the ideal next step in exacerbated movement disorder emergencies following medication trials and supportive measures. However, the evidence is limited and the logistical nuances of conducting a randomized controlled trial in the geriatric population would be ethically challenging.

Images in Vascular Medicine: Sudden mental status change and speech disturbance due to aortic echinococcosis.

Images in Vascular Medicine: Sudden mental status change and speech disturbance due to aortic echinococcosis.