Title : Case of neurocysticercosis in patient presenting with first episode psychosis
Abstract:
27-year-old hispanic male with no known past medical history initially presented to the emergency department for symptoms of possible panic attack after quitting his job and breaking up with his girlfriend. In the emergency department, he received oral Ativan 1 mg with reported improvement and was discharged home with hydroxyzine after normal laboratory testing. Due to patient presentation, no imaging was ordered at the time of ED visit. Patient was brought to our behavioral health emergency room two days later by family on voluntary status with primary complaints of being unable to sleep, feed, clothe, or seek treatment, in addition to complaints of paranoia, anxiety, and disorganized behavior.
Patient was a poor historian and an interview was conducted with his family. Per family, the patient immigrated from Mexico at a young age and previously worked for several years as a manager of a large commercial store. Patient was at his normal baseline mentation until that morning when he was found showering fully clothed and required assistance to move out of the shower. He was reported to have been experiencing increased emotional stressors over the past several months but did not exhibit any concerning symptomatology until that morning.
During the interview, the patient spoke only in Spanish despite reported long-time fluency in English. Patient exhibited disinhibition of speech with agitation, circumferential thinking and disorganization with statements such as “I don’t give a fuck” and "I don't want to talk about my past. I want to talk about who I am now and I am a shell of a human being". He was seen several times attempting to operate the water fountain with his foot but was able to be redirected. Additionally, the patient appeared guarded, anxious, and paranoid. Intake interview was terminated early after he exhibited escalated physical paranoid behaviors with unsuccessful verbal de-escalation and redirection.
Emergency medication intramuscular Geodon 20 mg and Ativan 20 mg was administered and the patient was admitted under 5150 for further evaluation and stabilization of grave disability. Considering patient demographic, acuity of onset, symptoms of paranoia, and executive functioning impairment, diagnosis was made of unspecified psychosis and possible syndromal schizophrenia. Initial workup was conducted to rule out organic causes of psychosis. Electrocardiogram, creatine kinase, lactate, urinalysis, coagulation studies, ammonia, venous blood gas, FTA-ABS, HIV, urine drug screen, salicylate level, acetaminophen level, Hepatitis C, cell blood count, complete metabolic panel, Vitamin D, and Vitamin B12 levels were ordered and results were unremarkable except for mild leukocytosis with white cell count of 12.9 x 10*3, mildly elevated absolute neutrophil count of 10.99 x 10*3 and a total creatine kinase level of 2,396. CT brain was ordered for additional workup of structural causes of psychosis.
CT brain results showed two calcified cysts related to possible old neurocysticercosis individually located in the right frontal and left parietal lobe. Patient was started on oral risperidone 2 mg twice daily and diphenhydramine 50 mg nightly for insomnia. Patient hospitalization in the first 48 hours was complicated by continued lack of orientation to place, refusal to eat, shower, or take psychotropic medications which required one additional dose of IM emergency medication. Due to lack of improvement in orientation and inability to complete any activities of daily living, patient was placed on a 5250 after initial hold expired.
There was also concern for catatonic behavior with mutism and social withdrawal for which the patient received an Ativan challenge with improvement of his negative symptoms. Over the next 24 hours, he began to improve rapidly with consistently demonstrated linear thought processes. He began to eat, perform personal hygiene, and actively participate on discharge planning. Patient agreed to pursue outpatient psychiatric follow up and declined psychotropic medications on discharge.
