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Acute psychosis as the initial presentation of MS: a case report.

Introduction

Multiple sclerosis (MS) is a common inflammatory demyelinating disease involving the central nervous system. Individuals with MS have an increased vulnerability to psychiatric disorders. Cross-sectional studies have revealed that nearly two-thirds of patients have detectable psychopathological conditions at some time, although not all require or receive psychiatric treatment. (1) Amongst psychiatric illnesses, mood disorders, especially depression, and cognitive disorders are commonly associated with MS. Psychotic illnesses have been reported less frequently in patients with MS, occurring at a rate of about 2-3%. (2) Psychosis has generally been reported to occur after extensive involvement of periventricular areas, especially the temporal regions and to occur after the onset of neurological symptoms. (3,4)

There are few reports of patients with MS presenting with pure psychiatric disorders without neurological symptoms. (5-8) Presentation as typical acute psychosis associated with stress is rarely reported in MS. Here, we present a case of a 30-year-old female in whom acute psychosis associated with stress was the initial presenting feature of MS and the patient developed neurological symptoms after some time and was then diagnosed as a case of MS.

Case Presentation

A 30-year-old married, graduate female working as a medical laboratory assistant presented with acute onset complaints of irritability, anger outbursts, suspicion that others were talking about her, that her work colleagues wanted to harm her and did not want her to transfer to her husband's laboratory, muttering and gesticulating to herself, along with disturbed biological functions and socio-occupational dysfunction of 15 days' duration. There was no past or family history of any psychiatric or neurological illness nor any viral infection preceding the symptoms or any other history suggestive of organic disease. Her personal history revealed that she had married 2 months before and since then had applied for a transfer to her husband's place of work. Due to official reasons, her transfer was delayed and she was under undue stress because of that, as reported by her husband.

Mental status examination revealed poor grooming and hygiene, increased psychomotor activity, rapport not established, eye-to-eye contact established, but not maintained, with irritable affect, delusions of reference and persecution, elementary auditory hallucinations and insight grade I/V. Her higher mental functions, including orientation, memory, judgement and abstract reasoning were normal. Mini mental status examination (MMSE) revealed a score of 28/30. No focal neurological deficit was found on examination and fundus examination was normal.

In view of the acute onset of psychotic symptoms and associated stress, a diagnosis of acute and polymorphic psychotic disorder associated with stress (F23.01) was made as per ICD 10. Routine haematological investigations, electrocardiogram and chest X-ray were normal. Quetiapine 25 mg per day increased to 150 mg per day over a period of 1 week along with lorazepam 4 mg per day decreased to 1 mg after 1 week was started. The patient was followed up after a period of 5 weeks wherein, improvement in psychotic symptoms was reported. However, the family members reported that unlike before, now she was not able to recollect the names of various things, she would often have memory problems, e.g. lose her way, she had also developed facial asymmetry with a deviation of angle of the mouth when smiling.

Examination revealed perplexed affect, impairment of immediate and recent memory, naming aphasia, slurred speech, up going left planters, and UMN-type left facial nerve palsy. MMSE score at this time was 21/30. She did not report any delusions or hallucinations at this time. In view of these findings, a magnetic resonance imaging (MRI) brain scan was carried out revealing extensive bilateral, multiple, white matter high signal lesions on T2 weighted images involving periventricular and callosal regions, with multiple nodular and ring enhancing lesion with some incomplete rings on Gadolinium contrast (Figure 1a, b, c).

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Subsequent neurological consultation was carried out. Other investigations, i.e. ANA, HIV, VDRL, serum caeruloplasmin levels, serum [B.sub.12] level, thyroid function tests were normal. CSF analysis showed normal cell count, glucose and proteins. CSF analysis for fungal infections and tuberculosis was negative. Polymerase chain raection for herpes simplex was also negative. An MRI of the spinal cord was shown to be normal. Slit lamp examination was negative for KF rings. VEP, SSEP and BAER investigations were also normal. In view of clinical and MRI findings, the possibility of MS versus acute disseminated encephalomyelitis (ADEM) were considered. She was prescribed steroids and she showed some improvement in symptoms over the following 3 months. However, she still had memory problems and naming aphasia. Her antipsychotic medication was continued in a dose of quetiapine 100 mg per day.

Because of the uncertainty as to whether the diagnosis was ADEM or MS, further interval investigations were undertaken 7 months after the acute presentation; no new clinical events had occurred. An MRI brain scan again showed periventricular bilateral multiple white matter lesions, exactly as before; however, there was no post-contrast enhancement reported (Figure 2a, b, c). CSF examination was again undertaken and was positive for oligoclonal bands. Repeat testing with the MMSE gave a score of 22/30. She had not been given disease-modifying therapies, but quetiapine was continued and steroids were tapered. She was advised to attend cognitive rehabilitation.

Discussion

Our patient was a young female who presented with acute psychotic symptoms and no neurological symptoms or signs on examination. There was no past history suggestive of any illness and the onset was temporally associated with stress. However, on follow up she developed neurological symptoms and an MRI brain scan was suggestive of MS. Our report highlights the fact that one should be careful while evaluating patients with a first-episode psychosis, even if it is associated with stress. Conceivably any psychiatric symptom that has been reported to occur in MS may be a presenting symptom. Studies on the prevalence of psychiatric onset of MS and the nature of symptoms at onset are limited and do not allow for general conclusions. Since cerebral involvement occurs almost universally in MS patients, it would not be surprising if occasionally the first detectable clinical features of MS were psychological rather than neurological symptoms. It has been concluded that around 1% of patients with MS have psychiatric onset of symptoms. (6)

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Felgenhauer (9) reported on 19 patients suffering from the encephalitic form of MS who presented with psychiatric symptoms; neurological signs were either absent or overlooked. One should also look for neurological signs in patients with first-episode psychotic illnesses and should investigate patients with positive signs as they may indeed represent clinically relevant dysfunction.

Psychosis in MS has been reported to be associated with significant periventricular lesions; especially in the temporal region. (4) Our patient also had extensive periventricular lesions. This finding also helps us in understanding the biological basis for psychosis and to understand the brain areas involved in psychosis.

Also, data regarding the management of psychotic symptoms in patients with MS is scarce and conflicting. Though steroids have the risk of exacerbating psychosis, some reports suggests successful use of steroids for psychotic symptoms also. (10) Atypical antipsychotics have also been used to manage psychotic symptoms. (11) In our case, these symptoms responded to quetiapine. Regarding differential diagnosis with ADEM, previously suggested operational criteria for this diagnosis may have shortcomings when used in the acute phase of illness. (12)

Our patient fulfills the MS category ([less than or equal to] 1 criterion) since oligoclonal bands were present and there was no radiological evidence of grey-matter involvement. The radiological findings were more suggestive of MS. (13) Hence, the likelihood of ADEM is low in this case.

Continued vigilance looking for signs compatible with central nervous system dysfunction, cognitive changes, atypical symptoms, detailed neurological examination and limited response to conventional psychotropic medication should be carried out for patients presenting with psychosis and even in follow-up period, as organic disorders may rarely present initially with only psychiatric symptoms without neurological signs and symptoms. One must not preclude a diagnosis of MS in the presence of other clinical, imaging and paraclinical features supportive of the diagnosis, although it may require the passage of time before a definite diagnosis can be established. Further studies are required to find the exact prevalence of patients with MS presenting initially with pure psychiatric symptoms and to study the factors associated with such a presentation.

Key Points

* Although psychiatric presentation is recognized in MS, acute psychosis associated with stress is rare.

* The differential diagnosis of acute onset psychosis with white matter demyelination are many and include MS, ADEM, cerebral vasculitis, infectious disorders, immunological disorders like Sjogren's syndrome, systemic lupus erythematosus and malignancies.

* Acute psychosis may be a rare presenting feature of MS.

* Definitive diagnosis may only become apparent with the passage of time.

Conflicts of Interest

No conflicts of interest were declared in relation to this article.

Received: 3 February 2010

Accepted: 11 February 2010

References

(1.) Rao SM, Reingold SC, Ron MA, Lyon-Caen O, Comi G. Workshop on neurobehavioral disorders in multiple sclerosis. Arch Neurol 1993; 50:658^.62.

(2.) Patten SB, Svenson LW, Metz LM. Psychotic disorders in MS: population based evidence of an association. Neurology 2005; 65:1123-1125.

(3.) Ron MA, Loosdail SJ. Psychiatric morbidity in multiple sclerosis: a clinical and MRI study. Psychological Medicine 1989; 19:887-895.

(4.) Feinstein A, du Boulay G, Ron MA. Psychotic illness in Multiple Sclerosis: A Clinical and Magnetic Resonance Imaging Study. Br J Psychiatry 1992; 161:680-685

(5.) Reimer J, Aderhold V, Lambert M, Haasen C. Manifestation of multiple sclerosis with paranoid hallucinatory psychosis. J Neurol 2006; 253:531-532

(6.) Jongen PJH. Psychiatric onset of multiple sclerosis. Journal of the Neurological Sciences 2006; 245:59-62

(7.) Matthews WB. Multiple sclerosis presenting with acute remitting psychiatric symptoms. J Neurol Neurosurg Psychiatry 1979; 42:859-863.

(8.) Kohler J, Heilmeyer H, Volk B. Multiple sclerosis presenting as chronic atypical psychosis. J Neurol Neurosurg Psychiatry 1988; 51:281-284.

(9.) Felgenhauer K. Psychiatric disorders in the encephalitic form of multiple sclerosis. J Neurol 1990; 237:11-18.

(10.) Mendhekar DN, Mehta R, Puri V. Successful Steroid Therapy in Multiple Sclerosis Presented as Acute Psychosis. JAPI 2004; 52:512-513

(11.) Chong SA, Ko SM. Clozapine treatment of psychosis associated with multiple sclerosis. Can J Psychiatry 1997; 42:90-91.

(12.) John L, Khaleeli AA, Larner AJ. Acute disseminated encephalomyelitis: a riddle wrapped in a mystery inside an enigma. Int J Clin Pract 2003; 57: 235-237.

(13.) Singh S, Prabhakar S, Korah IP, Warade SS, Alenxdra M. Acute disseminated encephalomyelitis and multiple sclerosis: Magnetic resonance imaging differentiation. Australas Radiol 2000; 44: 404-411.

A Aggarwal, DD Sharma, R Kumar, RC Sharma

Department of Psychiatry, Indira Ghandi Medical College, Shimla-171 001, Himachal Pradesh, India

Address for Correspondence

Ashish Aggarwal

Department of Psychiatry

Indira Gandhi Medical College

Shimla-171001

Himachal Pradesh

India

Tel: +91 0921 883 2616

E-mail: drashish1980@gmail.com
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Article Details
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Title Annotation:multiple sclerosis
Author:Aggarwal, A.; Sharma, D.D.; Kumar, R.; Sharma, R.C.
Publication:The International MS Journal
Article Type:Clinical report
Geographic Code:1USA
Date:Jul 1, 2010
Words:1809
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