Case report
In January 2020, a 31 years old Caucasian woman, with an underlying
diagnosis of moderate intellectual disability and a recent diagnosis of
Bipolar Affective Disorder in November 2019, was referred to her local
Emergency Department (ED) by her GP requesting medical work-up to
investigate thecause of new onsetimpaired mobility.
In the Emergency Department, she had blood investigationswhich showed an
increase in WBC and Neutrophils (respectively 14.4mmol and
10.53mmol).Chest Radiograph was unremarkable. Urine dipstick revealed
increased leukocytes anda Urinary Tract Infection (UTI) was diagnosed.
She presented with a history of new physical symptoms for around one
week:
- Slurring of speech (usually her family are able to fully comprehend
her)
- Not able to follow commands (usually compliant)
- Not able to use her hands (usually independent and able, for example,
to feed herself)
- Tremor in upper and lower limbs
She was referred back to ED staff for further organic work-up and she
was admitted to a medical ward.
One day following admission, she was referred to the Liaison Psychiatry
team, and a full collateral history was obtained from her treating
Intellectual Disability Consultant in the Community and her mother who
is her next of kin. On the same day a CT brain was performed and nothing
abnormal was detected.
Collateral history from mother/GP/ID Consultant
The patient had been living at home with her parents until 2016 until
the age of 27. She was attending the local Intellectual Disability day
services. She was first reviewed by an ID Consultant Psychiatrist in
2010 when she was diagnosed with Generalised Anxiety symptoms and
prescribed Citalopram 20mg OD. Subsequently she made a full recovery and
she remained on the same dose of Citalopram.
She was seen in a surgical ward in thehospital following a fall by the
ID Consultant in February and March 2016. At her first review, patient’s
mood was objectively anxious with separation anxiety in relation to
mother in particular. There was no evidence of psychotic symptoms. On
March,Citalopram 20mg od was stopped and Sertraline 50mg OD and a
Diazepam 1mg BD was started.
In October 2017,her father died and her grandmother who she was very
close to also died after two months. Following this, she was firstly
initially admitted to a Respite Unitdue to an enhanced level of care
required.
In April 2018 Sertraline was increased to 100mg OD because of anxiety.
For the same reason, in July 2018 Alprazolam 0.25mg BD + 0.25mg BD PRN
was started.
In August 2019, she started presenting with an increased level of
anxiety manifesting in repetitive questioning, sometimes irritability,
repeated requests for food, frequent requests to go to toilet and
periods of urinary incontinence. This was very much out of character for
her.
At this time, she starting attending another Intellectual Disability
Consultant Psychiatrist linked with the community home. In August 2019,
Alprazolam was discontinued and she was commenced on Lorazepam 1mg BD
PRN. In September 2019, also due to anxiety, Mirtazapine 15mg nocte was
commenced. In October 2019 Mirtazapine was increased to 45mg nocte and
Lorazepam was decreased to 0.5mg BD PRN. She was still on Sertraline
100mg OD at this time.
In November 2019, there was deterioration in her mental state. She had
early morning wakening, her mood appeared elated throughout day, she
demonstrated incessant speech, very repetitive speech with echolalia and
she could not sit still for long periods withouthyperactivity. Her
symptoms were consistent with an episode of hypomania and she was
diagnosed of Bipolar Affective Disorder.Sertraline was discontinued and
Quetiapine was started and gradually titrated up to 50mg mane + 75mg
nocte.
There was a slight reduction in her hypomanic symptoms, however she
still presented with pressured speech, flight of ideas and repetitive
behaviours. Her Mirtazapine was reduced to 30mg nocte. Olanzapine 5mg OD
+ Olanzapine 5mg BD PRN was commenced.
After around five days, her physical condition deteriorated. Her
mobility deteriorated and she became more withdrawn according to her
mother.At the same time, she was diagnosed with bronchitis by her GP.
She was prescribed the antibiotic Doxycyline and it was initially
thought that the impairment of the mobility was a side effect of the
antibiotic.
At review in January 2020 she appeared mildly elated. She was less
talkative, appeared calmer, was less repetitive and her responses
appeared more rational although grandiose in manner.
It was mentioned that she hadtwo dosesof PRN Olanzapine 5mg which
appeared effective to settle her mood.Olanzapine was increased to 5mg
BD.Quetiapine reduced to 25mg mane + 75mg nocte.Mirtazapine 30mg nocte
and Lorazepam 0.5mg BD PRN were left unchanged.
Unfortunately,she continued experiencing low grade fever, vomiting,
symptoms of UTI. Furthermore, she was less mobile and she started using
a wheelchair and there was an increase in behavioural
problems.Therefore, GP directed her to the local ED for further
investigation and management. Subsequently she was admitted to the
medical ward as mentioned above.
Course in Hospital in January 2020
At Liaison Psychiatry review, the morning following her medical
in-patient admission,she presented with symptoms suggestive of
neuroleptic malignant syndrome (NMS): fever (38.2°C), increased muscular
tone bilaterally in upper and lower limbswith cogwheel phenomenon. She
had in atremor in her upper and lower limbs, reduced mobility,
dysphagia, slurred speech, tachycardia (130 bpm), labile blood
pressure(140/102 –126/80), increased CK (1033mmol), increased WBC
(14.4mmol).
Collateral history was taken from her carer and her mother. They
reported that patient started experiencing physical symptoms and also
more sociallywithdrawn compared to her usual baseline soon after
Olanzapine 5mg once daily was started in December 2019. Her symptoms
subsequently deteriorated in January 2020 after Olanzapine was increased
to 5mg BD. At the time, she was also on Quetiapine 25mg once daily +
75mg nocte and Mirtazapine 30mg nocte.
It is relevant to mention that when she was on higher doses of both
Quetiapine and Mirtazapine there were no concerns in relation to her
physical health and that the symptoms suggestive of NMS started when
Olanzapine was increased.
Upon Liaison Psychiatry review the first day of her admission, her
Olanzapine and Quetiapine were both discontinued and she was commenced
on Diazepam 1mg TDS and it was increased to 2mg TDS the following day.
She was also commenced on Lorazepam 0.5mg QDS PRN but it was not
necessary to give her this medication at any stage during the course of
her medical admission. The day after, Mirtazapine was reduced to 15mg
nocte.
During the course of her medical admission she was regularly reviewed by
the Liaison Psychiatry team, her mental state appeared stable.
Her physical condition improved during her admission. CK and WBC
decreased respectively to 499 mmol and 9.8 mmol after one week.
On discharge after a 10 day admission, patient presented with
objectively euthymic mood, no evidence of distress, no agitation.
Nilpsychotic symptoms were elicited. She presented brighter, appropriate
in her conversation and appeared at baseline; with no pyrexia, normal
Blood pressureand heart rate and, normal muscle tone in all four
limbs.She was discharged on Diazepam 2mg TDS and Mirtazapine 15mg
nocte.Her mother reported that she was back to her usual premorbid
baseline.
The patient was medically admitted again to University Hospital
Waterford twelve days after her previous dischargefor treatment of a
UTI. Her CK level was 100 mmol on admission.She was regularly reviewed
by the Liaison Psychiatry team and she always presented in a stable
mental state and without features suggestive of NMS on this
2nd admission. There was no evidence of psychomotor
agitation. Her speech was repetitive but comprehensible although it
remained mildlyslurred. Her mood was euthymic with reactive affect. Nil
psychotic symptoms were elicited. She was alert and aware of her
surroundings.She was discharged after one week on Diazepam 2mg TDS and
Mirtazapine 15mg nocte. She is now being treated by the Learning
Disability Team in the Community. She has remained physically well since
her last discharge from hospital six (so far) months ago.
At the time this case report is written (November 2020), the patient has
remained stable on a mental state view point and she is maintained on
Mirtazapine 15mg nocte, Valproate Chrono 500mg BD, Depo-Provera 150mg IM
every 12 weeks (long acting contraception), Clonazepam 0.5mg PRN max BD.