Maldonado referred to late stage Lyme disease, with a predominance of cognitive, psychiatric, and neurological symptoms, as neuroborreliosis. From a purely psychiatric perspective, the most common symptom of neuroborreliosis is depression.
“I have seen many patients with Lyme disease and find it difficult to tell whether the depression is primary or secondary,” Maldonado said. Less common symptoms include panic attacks; transient paranoia, illusions, or hallucinations; anorexia; depersonalization; violent outbursts; obsessive-compulsive disorder; agitated mania; sensitivity to light or sound; and personality changes.
Several tests aid in diagnosis, including the serological studies with enzyme-linked immunosorbent assay, Western blot, or polymerase chain reaction (PCR) for borrelial DNA. One problem is that these serological studies may be equivocal, he said. A PET scan is helpful because it shows global or heterogeneous hypoperfusion; an MRI scan may show signs of demyelination.
If there is no CNS involvement, treatment is usually a long course of doxycycline(Drug information on doxycycline) (Vibramycin and others), amoxicillin(Drug information on amoxicillin) (Amoxil and others), or cefuroxime (Ceftin). With CNS involvement, the regimen is 4 to 6 weeks of IV ceftriaxone(Drug information on ceftriaxone) (Rocephin) or cefotaxime(Drug information on cefotaxime) (Claforan).
Herpes infection. More than 1 in 5 adult Americans have genital herpes, and 50% to 80% of American adults have oral herpes, according to the American Social Health Association. Herpes simplex virus (HSV) is the etiological agent for herpes simplex encephalitis (HSE); up to 70% of untreated cases of HSE are fatal.
HSE, Maldonado said, is characterized by an abrupt onset of fever, personality changes, and headaches, followed by cognitive changes and focal neurological signs (such as aphasia). Neuropsychiatric symptoms include an initial presentation with hallucinations, memory loss or behavioral disturbances, progression to refractory seizures, coma, and possibly death. Survivors may exhibit postencephalitic symptoms of amnesia, aphasia, and Klüver-Bucy syndrome or dementia.
Leukocytosis, moderate protein elevation, and a normal or depressed glucose level in cerebrospinal fluid are some diagnostic clues. PCR analysis will detect HSV DNA, and a brain MRI can detect inflammation.
HSE is treated with the antivirals acyclovir (Zovirax) and vidarabine(Drug information on vidarabine) (Vira-A).
Connective tissue disease
Systemic lupus erythematosus (SLE) is characterized by recurrent episodes of destructive inflammation of several organs including the skin, joints, kidneys, blood vessels, and CNS. Psychosis, cognitive defects, and dementia have all been described as psychiatric manifestations of SLE.
“About 5% of patients suffering from lupus cerebritis have psychosis, usually within the first 2 years of having the disease,” said Maldonado. “But physicians need to distinguish between steroid psychosis and SLE psychosis.”
Treatment for SLE psychiatric symptoms can include corticosteroids, cyclophosphamide(Drug information on cyclophosphamide) (Cytoxan) and, possibly, antipsychotics.
Maldonado, who has focused on delirium in his research, emphasized that it is the most common neurobehavioral disorder among medically ill patients in general hospitals. Its incidence ranges from about 15% in the general medicine wards, to 40% in surgical wards, to up to 80% in the ICUs. A single cause for delirium is seldom identified, he said, but the most common risk factors include older age, baseline cognitive functioning, male gender, the use of exogenous agents with high anticholinergic load (usually associated with illicit or prescribed substances), immobility or physical restraints, sleep deprivation, and the severity of the underlying medical illness process.
Understanding, preventing, and treating delirium is important because of the severe consequences it carries greater morbidity and mortality; longer hospitalizations, higher incidence of placement in extended care facilities, and increased cost of care; and permanent cognitive impairment or development of other psychiatric disorders, such as posttraumatic stress disorder, he said.
“The condition is often missed or misdiagnosed by general medical practitioners.” Maldonado added that “it is an area where psychiatrists can have a great impact.”
Extensive information about delirium can be found in 2 articles by Maldonado in the October 2008 issue of Critical Care Clinics. One article proposes a pathoetiological model of delirium, and the second discusses the characteristics, diagnosis, and treatment of delirium.
The bottom line, cautions Maldonado: keep in mind that medical or neurological illnesses may be contributing factors to a patient’s neuropsychiatric symptoms.