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Consider Acute Viral Encephalitis With Unexplained Psychosis.

Familiarity with the clinical signs and epidemiology of encephalitis is critical in avoiding misdiagnosis of this elusive condition which often presents as a psychiatric disorder, said Dr. Stanley N. Caroff and his associates at the University of Pennsylvania in Philadelphia.

The researchers reviewed 108 published cases of psychiatric disorders that had suspected or confirmed viral infections of the central nervous system. The psychiatric symptoms, which initially presented as encephalitis, were clustered into four major syndromes: acute psychosis (35%), catatonia (33%), depression with psychotic features (16%), and mania (11%).

These presentations were not mutually exclusive, the researchers said; a patient could, in fact, manifest symptoms of several syndromes (Psychiatric Annals 31[3]:193-202, 2001).

Because these psychiatric symptoms are nonspecific, they are often difficult to distinguish from classical psychiatric disorders--especially in the absence of obvious neurologic symptoms. The investigators recommended taking careful note of symptoms such as headaches, fever, disorientation, or seizures.

The presence of nausea, vomiting, extrapyramidal signs and oculomotor dysfunction also provide important clues, they said.

"It is critical that subtle cognitive deficits or neurologic signs and symptoms not be dismissed in the context of bizarre behavior," the investigators said. The presence of fever and headache in a patient that has recently been diagnosed with schizophrenia should prompt further investigation for encephalitis.

Other potential clues that point to underlying encephalitis include the absence of a personal or family history of psychopathology, proximity to epidemic or endemic illnesses within the community or among animals, and a report of recent recovery from respiratory Or other viral illness.

If encephalitis is suspected, lumbar puncture should be performed after neuroimaging and electroencephalogram. The cerebrospinal fluid also should be examined in order to exclude nonviral pathogens such as bacteria, fungi, or parasites.

The most important aspect of treatment is recognizing encephalitis and identifying the pathogen so that appropriate antiviral therapy can be initiated.

Neuroleptics may he useful at low doses in managing behavioral manifestations, but careful monitoring is essential because of the susceptibility of these patients to neurologic side effects, Dr. Caroff said.
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Publication:Clinical Psychiatry News
Date:Jun 1, 2001
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