Neurosyphilis Psychiatric Manifestations HPI 62yo AAM 5 to 6 months “making funny sounds with mouth, as if smacking when eating”, w/ patient unaware of

NeurosyphilisPsychiatric Manifestations

HPI62yo AAM5 to 6 months

“making funny sounds with mouth, as if smacking when eating”, w/ patient unaware of behavior

2 months bilateral upper extremity tremor

Referral to Caddo Health Unit 3/17/05 w/ +RPR @ 1:16 dilutions-benzathine penicillin @ 2.4 million units IM 4/5/05 and 4/12/05

1 monthprogressive deterioration of speech confusion w/ obvious cognitive declinebizarre behavior (disconnecting appliances, moving furniture)paranoid ideations, w/ delusions of jealousyA/VHheadaches, decreased vision OS


PPH

None

PSH

Prostate hypertrophy, w/ TURP (9/03)

Repair of incarcerated right inguinal hernia (4/05)

PMH

Hypertension


FH- Alzeimer’s dementia (mother)?

SH- Born in Gloster, LA by unremarkable home delivery

3rd of 7 children, w/ no reported developmental issues

Parents described as “the best people I had”

12th grade education (“a good basketball player”, + contact w/ teachers)

Work x 39y as truck driver (“18 wheeler”); current $ from SS + wife’s job

Lives w/ common law wife of 29y (24yo daughter + 2 other adult children)

Rare church attendance, no military, no legal issues/incarceration

Tobacco @ 50 PY (abstinence beginning w/ current illness)

No ETOH or illicit substances


ROSUpper extremity tremorRecurrent headachesDecreased visual acuity, OS

PEBP=162/93, P=112, T=98.8Neurological-

Slightly agitated, w/ resting (“adrenergic”) tremorAlert but disoriented, dysarthricCranial nerves 2 to 12 intact, w/ unremarkable pupils and fundiMotor/sensory intact, w/ normal DTR’s and no abnormal reflexesNo ataxia, w/ “steady” gait; negative Romberg


MSE (admission)

Casual attire, w/ some neglect in grooming, tatoo on left arm

Chronic resting tremor, facial “twitch”

Cooperative, but decreased eye contact

Incoherent speech (slurred and broken)

Appearance of depression, w/ “constricted” emotional expression

No appearance of response to internal stimuli

Unable to assess thought processes, but appearing confused

No suggestion of violent ideations

Alert, but disoriented as to year

Decreased attention/concentration

Decreased early recall

Limited insight/judgement (unable to identify reason for hospitalization)

MMSE=18/30 (4/18/05)


Hospital Course Laboratory: CBC wnl (wbc=8.08)

CMP wnl, except glucose=118U/A wnlUDS negative, ETOH<10ESR=25Folate/B12 levels wnlTSH wnlHIV negativeRPR reactiveFTA-ABS reactiveMHA-TP reactive

Brain CT-normal study


Hospital Course

Neurology Consultation: EEG-negative for seizure activity

MRI-bilateral frontal and basal ganglia changes,

consistant w/ encephalomyelitis (viral vs metabolic)

LP-clear/colorless CSF

OP=18 cm of water

wbc=0, rbc=117

glucose=60, protein=37

stains/cultures negative for fungus, AFB, bacteria

Cryptococcus Ag latex negative

VDRL reactive at 4 dilutions


Hospital CourseInfectious Disease Consultation:

Encephalitis panel (r/o viral etiology) + Ab

HSV, CMV, measles - Ab

Eastern and western equine, California, Saint Louis, LCM, adenovirus, influenza, Varicella zoster, cocksackie, echovirus, mumps

Penicillin G IV @ 4 million units q4h x 14 daysBenzathine penicillin @ 2.4 million units IM q week x 3

doses F/U w/ RPR and VDRL at 3, 6, and 12 months


Hospital Course

Opthamology consultation:

Choreoretinitis OS, consistent w/ neurosyphilis

F/U at 6 months, after completion of antibiotic regime

Audiology testing: Bilateral sensorineural hearing loss


Hospital CourseNeuropsychiatric Testing:

Lezak Memorization of 16 Items“Statistically deviant”

Dementia Rating Scale“Severely impaired”

Weschler Abbreviated Scale of IntelligenceIQ (full scale)=61 Wide Range Achievement TestReading/spelling within “severe learning d/o” classification;arithmetic at “low average” Thermatic Apperception Test

Data suggestive of “…proneness to withdraw from social conflict”

Impression-Dementia due to medical condition


Hospital CoursePsychopharmacologic Management:

4/18/05-Lorazepam 1 mg PO q12h prn agitation/aggressive behavior

4/21/05-Risperidone 1 mg PO bid

Trazodone 50 mg PO HS

Lorazepam 2 mg IM

4/24/05-Haloperidol 5 mg/Lorazepam 2 mg/Diphendramine 50 mg IM 5/2/05-Risperidone 1 mg PO HS

5/4/05-Haloperidol 5 mg/Lorazepam 2 mg/Diphendramine 25 mg IM


Hospital CourseMSE (discharge, 5/12/05)

GroomedBehavior appropriateSpeech coherent, although slow and softEuthymic, affect congruentSome paranoia; no evidence of A/VHAlert, oriented to self and timeReduced memoryLimited insight/judgment

Neurological exam (discharge)Normal


Hospital Course

Discharge (5/12/05)

Medications

Risperdal 1 mg HS

ASA 81 mg/d

F/U

Psychiatry Clinic, 6/9/05

Opthamology Clinic, 10/05STD Clinic, 5/19/05CCC, prn


Clinic F/UMSE (2/16/06)

Casual, groomed/cleanCooperative, w/ good eye contactLimited perioral movement (rated at level 1 on AIMS)Paucity of speech, yet coherent; minor stuttering/hesitation (lifetime history)Language: +Object naming, repeating (“no ifs, ands, or buts”) +Following 3-stage command, reading and obeying, design copying -Unable to write a sentence Mood “all right”, blunted affectPerception clear w/o apparent A/VH or paranoiaThought clear, organized and goal-directed w/o violent ideationsAlert and oriented to all parametersRegistration=3/3, recall at 3 to 5 minutes=2/3100-7=93-7=?(25-5=20-5=15, 2+2=4+4=8+8=16); unable to spell “ WORLD”

backwards“Don’t cry over spilled milk”~”Don’t interfere in anything.”Insight and judgment fair


Clinic F/U

MMSE

4/18/05-19/30

1/10/06-21/30

2/07/06-23/30

Medications

Risperidone 1 mg HS

Namenda 10 mg/d (begun 10/19/05)

Clonidine 0.1 mg bid


Named for the mythical swineherd Syphilis,

accursed with the disease by Apollo

First described in a Latin poem written by an Italian physician

Rampaged across Europe in the 1400’s,

soon becoming endemic to much of the world

True origin a mystery,

possibly returned to Europe from native North Americans

Became known as the French disease, and “the great imitator”

Hutto B. Syphilis in clinical psychiatry: A review.

Psychosomatics 2001;42:453.


Kraft-Ebbing demonstrated association to general paresis in 1897

Prior to 1945, general paresis reportedly involved in 5% to 10%

of all first psychiatric admissions

Scheck DN, Hook E III: Neurosyphilis.

Infect Dis Clin North Am 1994;8:769.

In 1920s, >20% of patients in US mental hospitals with tertiary syphilis

Brandt AM: No Magic Bullet:

A social History of Venereal Disease in the United States Since 1980.

New York, Oxford University Press, 1987.

In 1997, overall rates of syphilis decreased to lowest levels ever

and US Public Health Service targeted disease for elimination

St Louis ME, Wasserheit JN.

Elimination of syphilis in the United States.

Science 1998;281:353.


Included in psychiatric differential diagnosis for:

Dementia

Psychosis

Mood disorders

Incidence presenting initially with psychiatric symptomatology unclear

Classic syndromes such as tabes dorsalis now less common than asymptomatic presentation versus manifestations such as

seizures or ocular and auditory involvementScheck DN, Hook E III: Neurosyphilis.

Infect Dis Clin North Am 1994;8:769.


Objectives:1. Review the pathophysiology of neurosyphilis, emphasizing psychiatric manifestations;

2. Raise awareness of the importance of routine screening for latent syphilis in psychiatric patients, particularly those presenting with psychosis and mood disorders as well as

dementia;

3. Encourage aggressive pharmacologic management of both the medical and psychiatric components of the illness, with realistic expectations of favorable results.

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Neurosyphilis Psychiatric Manifestations HPI 62yo AAM 5 to 6 months “making funny sounds with mouth, as if smacking when eating”, w/ patient unaware of