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Psychiatric Aspects of Non-HIV Infectious Diseases Robert K. Schneider, MD Michael J. Robinson, MD James L. Levenson, MD Why Now? • Global Society – Increased Travel – Increased Immigration/Emigration • Broader Medical Management – HIV – Malignancies – Transplantation • People living longer Infectious Disease Syndromes Chapter 52 Robert K. Schneider James L. Levenson Risk Groups Immune Status Demographics Risk Groups • Immune Status – Elderly – Chronic Disease • • • • HIV Malignancy Transplant Diseases where immunosuppressants are used – (ie SLE, Psoriasis, IPF) – Substance Abuse Risk Groups • Demographics – – – – – Children Recreational Activities Occupation Region of origin or residence Travel Assessment • Consider infectious causes when patient is in the risk group – Immune Status – Demographics • Activate an appropriate differential diagnosis • Know the best tests to evaluate these patients • Know the best treatments for these conditions Case One Postpartum Woman with Psychosis Postpartum Woman with Psychosis • 34 yo woman 4 weeks postpartum • 3 week history of paranoid ideation and auditory hallucinations • Other points on history? Postpartum Woman with Psychosis • Recently emigrated from Mexico • The family reports seizure disorder since age 3 • Several family members have seizures • Family reports no substance abuse What’s the differential diagnosis? • • • • • Postpartum psychosis Ictal or interictal psychosis Substance Abuse Malignancy Infectious causes – – – – Brain Abscess Toxoplasmosis Neurocysticerosis Tuberculosis Postpartum Woman from Mexico • EEG: “normal” • Urine Drug Screen: Negative (collateral family hx supports this) • • • • • CXR: normal CBC: 7,000: 60 neut; 5 eos; 30 lymph; 5 mono Hct: 40% Biochemical Profile: WNL HIV: negative Postpartum Woman from Mexico • Head CT with and without contrast: multiple cystic and calcified lesions • CSF: – – – – 24 WBC all lymphs Protein and Glucose: wnl Stains: negative Cultures: pending • Serology: – Pending Differential Diagnosis:Toxoplasmosis • Exceedingly common in general population • Disease occurs only in immunocompromized host • Most common treatable cerebral lesion in HIV • CT: ring enhancing lesions • CSF: pleocytosis • Serology: antibody positive 67% Differential Diagnosis:Tuberculosis • 15% extrapulomanry • Most CNS TB is parameningeal – Cerebral TB is very rare • CT scan: negative or meningeal granulomas • CSF: almost always reactive – – – – Depressed glucose Increased WBC Markedly elevated protein Stains positive 25%/Cultures positive 75% Differential Diagnosis:Brain Abscess • Patient usually with evidence of systemic infection • History of IVDA, Valvular heart disease or recent neurosurgery • CSF: virtually always positive, particularly on stains showing organisms Neurocysticercosis • The “Pork Tapeworm” • Caused by the larval form of Taenia solium • Most widely disseminated neuroparasitosis • CNS is the most frequently affected organ (92%) • Most common cause of seizures in endemic areas • Endemic in Latin America, sub-Saharan Africa, India and China Classification • Inactive disease • Active disease – – – – Parenchymal Ventricular Subarachnoid Spinal and ocular Neuroimaging • CT scan is the primary means of diagnosis • Most commonly reveals inactive disease – <1 cm calcifications – Hydrocephalus is evident secondary to obstructive intraventricular disease • Active Disease – Ring enhancing cystic lesions – Pathognomonic scolex is sometimes seen in the cyst – Meningeal disease is hard to detect on CT How good is serology in NCC? • CDC immunoblot assay • Acknowledged as immunodiagnositic by: – World Health Organization – Pan American Health Organization • 100% specific • Sensitivity varies: – Multiple lesions: 90% – Single enhancing parenchymal cysts: <50% – Clinically defined patients with calcified cysts: 70% What are the Psychiatric Aspects of NCC? • Depression: >50% in outpatient setting • Psychosis: 14% in outpatient, probably higher at presentation (inpatient) • Delirium often present at presentation • Cognitive decline and symptoms of hydrocephalus • Headache is common but nonspecific What’s the best treatment? • If inactive disease, no treatment except for the seizure disorder. • If active disease, corticosteroids and praziquantel is the main stay. • However, praziquantel is toxic and recent RCT suggest no benefit over symptomatic treatment. • In hydrcephalus (usually inactive, chronic NCC) surgically shunting is indicated. What areas of the US is NCC rising? • Prevalence in US is increasing, especially in areas with high immigrant populations – (eg Texas, California) • Most cases occur among Latin American immigrants • Local transmission is probably higher than expected Does NCC occur in travelers? • Yes • Can occur with only brief contact • Risk increases the longer the contact Cysticercosis surveillance: Locally acquired and travel-rated infections and detection of intestinal tapeworm carriers in Los Angeles Count. Sorvillo FJ, Waterman SH, Richards FO, Schantz PM. Am J Trop Med Hyg. 1992;47(3),365-371. Are you safe if you don’t eat pork? • No • Most transmission occurs from eating food that is fertilized with pork or human waste • Also carriers that are food handlers can transmit T. solium • NCC occurred in an Orthodox Jewish community in New York City. Infection was secondary to food handlers who were carriers of T solium Neurocysticerosis in an Ortodox Jewish Community in New York city. Schantz PM, Moore AC, Munoz JL, et al. NEJM 1992;327:692-5 Wrap up and questions ? Case Two The Pediatric Patient The Case • LR is a 5 year old girl who presents with the following complaints from her parents: • HPI: – “she has recently started to obsess about everything” – “she is constantly counting to four” – “everything has to be in its certain place or she gets really upset” The Case – “she repeatedly blinks” and “jerks her head the the side” – “she later started to do things with her voice” – Other associated behavior complaints • Recent PMHx: – sick with a fever on and off for the last few months – CXR - normal – No other investigations have been performed The Case • Past Psych Hx: – None; No emotional, behavioral, or school problems noted • Past Medical Hx: – early childhood recurrent otitis media, not requiring myringotomy tubes or prophylactic antibiotics The Case • Family hx: – first of 2 children; healthy younger brother – maternal hx of depression responsive to antidepressant medications – maternal grandmother with a hx of trichotillomania – paternal hx of vocal tics as a child – No OCD, No Sydenham’s chorea, No Rheumatic fever Differential Diagnosis • • • • • • • OCD ADHD Separation Anxiety PANDAS Sydenham’s Chorea Transient Tic Disorder Tourette’s Disorder / Chronic Motor or Vocal Tic Disorder Initial Work-Up? • Throat Culture Positive for GABHS • Anything else? – MRI? – D8/17? – Anti-GABHS antibody titres? Which ones? PANDAS • PANDAS = ? • Inclusionary Criteria: – – – – – Presence of OCD and/or tic disorder Pediatric onset Episodic course of symptom severity Association with GABHS infection Association with neurological abnormalities PANDAS • Proposed Pathogenesis: – Pathogen + Susceptible Host Immune Response Sydenham’s Chorea or PANDAS PANDAS • Association with GABHS? – Positive throat culture • Is a positive throat culture enough to demonstrate recent GABHS infection? – Elevated ASO and/or AntiDNase-B titres • Are elevated titres enough to demonstrate recent GABHS infection? – Can a child have a relapse of symptoms without evidence for a recent GABHS infection? PANDAS • Any other investigations? – Is an MRI warranted? – What is the significance of B-lymphocyte antigen D8/17? Should we test for it? 50 1000 40 800 30 600 20 400 10 200 0 0 0 2 4 6 8 10 12 14 Time (Months) C-YBOCS Ratings IVIG Treatment Tourette Syndrome Unified Rating Scale AntiDNAse-B titres Antibody Titre (IU/ml) Ratings Example Relationship Between AntiDNAse-B titres and Ratings of OCD and Tourette's PANDAS - Treatment Options • Antibiotics? – Acute treatment and/or prophylaxis? • Plasma exchange/Plasmaphoresis • Intravenous immunoglobulin Discussion & Questions Case Three Tick-bitten Hikers • 35 year-old woman, hiked Appalachian Trail • One week: flu-like symptoms, large rash on groin, facial palsy, Lyme serology negative • Two months: headache, stiff neck, arm numb and burning • One year: depression, fatigue, forgetful • 36-year-old man, hiked Glacier National Park • One week: flu-like symptoms, parethesias in hands and feet • Two months: headache, stiff neck, fatigue, Lyme serology positive • One year: depression, fatigue, diffuse myalgia Lyme Disease • • • • Caused by spirochete, Borrelia burgdorfei Transmitted by deer ticks (<5% risk) Over 10,000 cases/year reported in U.S. Over 90% from 8 states (CT, RI, NY, NJ, PA, MD, WI, MN) The Deer Tick Incidence of Lyme per 100,000 Disease Onset (One week) • Erythema migrans, >90% • Central clearing, <40% Erythema Migrans Acute Disseminated Disease (First month) • • • • • Fatigue, 54% Myalgia/arthralgia, 44% Headache, 42% Fever/chills, 39% Stiff neck, 35% Subacute Disease (Months) • Arthritis, oligoarticular, most often knee, 60% • Secondary skin lesions, 50% • Neurological, 15% – Cranial neuropathy, most often VII – Meningitis – Painful radiculopathy • Carditis (conduction disturbance), 5-10% Chronic Disease (Years) • Dermatitis • Arthritis • Neurological – Mild sensory radiculopathy – Cognitive dysfunction – Depression Chronic Neuroborreliosis – Diagnostic Tests • • • • CSF abnormal (>50%): protein, Ab positive MRI abnormal (25%): White matter lesions EEG normal Neuropsych testing abnormal Lyme disease is a clinical diagnosis Serology can support but not make diagnosis Serology • Two step • Initial: ELISA (or IPA) • If positive: Western blot Serology Limitations • False negative in early infection • False negative after early antibiotics • False positive in other infections, autoimmune diseases • True positive uncorrelated with time or activity Treatment • Acute disease: – oral doxycycline or amoxicillin, 2-4 weeks • Neuroborreliosis: – IV ceftriaxone, 2-4 weeks • Complete recovery is the rule Prevention • Prophylaxis not recommended after tick bite • Cover up and DEET • Vaccine effective – 50-70% first year – 75-90% second year • 35-year-old woman, hiked Appalachian Trail • One week: flu-like symptoms, large rash on groin, facial palsy • Two months: headache, stiff neck, arm numb and burning • One year: depression, fatigue, forgetful • 36-year-old man, hiked Glacier National Park • One week: flu-like symptoms, parethesias in hands and feet • Two months: headache, stiff neck, fatigue, Lyme serology positive • One year: depression, fatigue, diffuse myalgia Differential Diagnosis • • • • • • • Fibromyalgia Chronic fatigue syndrome Other infections Somatoform disorders Depression Autoimmune diseases Multiple sclerosis Consequences of Overdiagnosis & Overtreatment • Somatization • Invalidism • Antibiotic side effects “Lyme colitis” (Clostridia enteropathy) Questions?