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Neurosyphilis Psychiatric Manifestations

Neurosyphilis Psychiatric Manifestations . HPI 62yo AAM 5 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-

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Neurosyphilis Psychiatric Manifestations

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  1. NeurosyphilisPsychiatric Manifestations HPI 62yo AAM 5 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 month progressive deterioration of speech confusion w/ obvious cognitive decline bizarre behavior (disconnecting appliances, moving furniture) paranoid ideations, w/ delusions of jealousy A/VH headaches, decreased vision OS

  2. NeurosyphilisPsychiatric Manifestations PPH None PSH Prostate hypertrophy, w/ TURP (9/03) Repair of incarcerated right inguinal hernia (4/05) PMH Hypertension

  3. NeurosyphilisPsychiatric Manifestations 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

  4. NeurosyphilisPsychiatric Manifestations ROS Upper extremity tremor Recurrent headaches Decreased visual acuity, OS PE BP=162/93, P=112, T=98.8 Neurological- Slightly agitated, w/ resting (“adrenergic”) tremor Alert but disoriented, dysarthric Cranial nerves 2 to 12 intact, w/ unremarkable pupils and fundi Motor/sensory intact, w/ normal DTR’s and no abnormal reflexes No ataxia, w/ “steady” gait; negative Romberg

  5. NeurosyphilisPsychiatric Manifestations 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)

  6. NeurosyphilisPsychiatric Manifestations Hospital Course Laboratory: CBC wnl (wbc=8.08) CMP wnl, except glucose=118 U/A wnl UDS negative, ETOH<10 ESR=25 Folate/B12 levels wnl TSH wnl HIV negative RPR reactive FTA-ABS reactive MHA-TP reactive Brain CT-normal study

  7. NeurosyphilisPsychiatric Manifestations 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

  8. NeurosyphilisPsychiatric Manifestations Hospital Course Infectious Disease Consultation: Encephalitis panel (r/o viral etiology) + Ab HSV, CMV, measles - Ab Eastern and western equine, California, Saint Louis, LCM, adenovirus, influenza, Varicellazoster, cocksackie, echovirus, mumps Penicillin G IV @ 4 million units q4h x 14 days Benzathine penicillin @ 2.4 million units IM q week x 3 doses F/U w/ RPR and VDRL at 3, 6, and 12 months

  9. NeurosyphilisPsychiatric Manifestations 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

  10. NeurosyphilisPsychiatric Manifestations Hospital Course Neuropsychiatric Testing: Lezak Memorization of 16 Items “Statistically deviant” Dementia Rating Scale “Severely impaired” Weschler Abbreviated Scale of Intelligence IQ (full scale)=61 Wide Range Achievement Test Reading/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

  11. NeurosyphilisPsychiatric Manifestations Hospital Course Psychopharmacologic 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

  12. NeurosyphilisPsychiatric Manifestations Hospital Course MSE (discharge, 5/12/05) Groomed Behavior appropriate Speech coherent, although slow and soft Euthymic, affect congruent Some paranoia; no evidence of A/VH Alert, oriented to self and time Reduced memory Limited insight/judgment Neurological exam (discharge) Normal

  13. NeurosyphilisPsychiatric Manifestations Hospital Course Discharge (5/12/05) Medications Risperdal 1 mg HS ASA 81 mg/d F/U Psychiatry Clinic, 6/9/05 Opthamology Clinic, 10/05 STD Clinic, 5/19/05 CCC, prn

  14. NeurosyphilisPsychiatric Manifestations Clinic F/U MSE (2/16/06) Casual, groomed/clean Cooperative, w/ good eye contact Limited 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 affect Perception clear w/o apparent A/VH or paranoia Thought clear, organized and goal-directed w/o violent ideations Alert and oriented to all parameters Registration=3/3, recall at 3 to 5 minutes=2/3 100-7=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

  15. NeurosyphilisPsychiatric Manifestations 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

  16. NeurosyphilisPsychiatric Manifestations 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.

  17. NeurosyphilisPsychiatric Manifestations 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.

  18. NeurosyphilisPsychiatric Manifestations 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 involvement Scheck DN, Hook E III: Neurosyphilis. Infect Dis Clin North Am 1994;8:769.

  19. NeurosyphilisPsychiatric Manifestations 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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