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Neuroleptic malignant syndrome (NMS), a potentially life-threatening neurological emergency characterized by muscle rigidity, altered mental status (AMS), autonomic instability, and hyperthermia, is most commonly precipitated by high-potency first-generation antipsychotics due to central dopamine receptor blockade. There is a heightened risk of NMS in animals with ischemic brain injury (IBI) or traumatic brain injury (TBI) due to the resulting death of dopaminergic neurons from injury and the dopamine receptor blockade elicited upon recovery. To the best of our knowledge, this will be the first documented case of a critically ill patient, with a history of prior exposure to antipsychotics, who suffered an anoxic brain injury with subsequent development of NMS after the initiation of haloperidol for the treatment of acute agitation. Further investigation is necessary to expand upon the existing literature suggesting the role of alternative agents, including amantadine, due to its impact on dopaminergic transmission, as well as dopamine and glutamine release. Furthermore, NMS can be difficult to diagnose due to variable clinical presentation and lack of absolute diagnostic criteria, which is further compounded with central nervous system (CNS) injury, where neurological abnormalities and AMS may be attributed to the injury, rather than a medication effect, especially in the early period. This case highlights the significance of prompt recognition with appropriate treatment of NMS in vulnerable and susceptible patients suffering from brain injury.
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Description Gender dysphoria occurs when a discrepancy between one's sex assigned at birth and one's gender identity causes distress or impairment in function, which can lead ultimately to seeking treatment in the forms of psychotherapy, hormonal therapy, and/or gender-affirming surgery. Clinical care guidelines also recommend pharmacological treatment of psychiatric comorbidities if indicated. A review of the current literature demonstrates comorbidity between gender dysphoria and psychosis, including cases of gender dysphoria with schizophrenia and the occurrence of gender dysphoria symptoms during manic or psychotic episodes. The existing literature has yet to specifically examine gender dysphoria amongst individuals with schizoaffective disorder. The authors present the first documented case of a clear pattern of gender identity variations coinciding solely with psychotic episodes during schizoaffective disorder, bipolar type. The authors postulate that gender dysphoria can co-occur with other psychiatric disorders or may correspond only during acute psychosis. The distinction is critical to make to ensure accurate diagnoses regarding whether gender dysphoria is a symptom only during an acute psychotic illness, or if there is a longer-standing concern as to the patient's gender identity and assignment. This distinction then also informs how to make the most appropriate treatment recommendations. The authors address the significance of understanding each patient's individual circumstances and deem this paramount to advancing transgender and gender non-binary health equity at every level of medical attention, focusing specifically on proper physician training and direct patient care.
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Introduction: Charles Bonnet Syndrome (CBS) refers to visual hallucinations in visually impaired patients without psychiatric illness who are typically aware that their hallucinations are not real. Rare cases in the literature describe patients with atypical CBS, or CBS plus, who experience hallucinations in the context of sensory deficits but do not meet all of the criteria of a CBS diagnosis. These cases may include hallucinations in more than one sensory modality, including auditory hallucinations, which are thought to arise by a similar pathophysiology to that of the visual hallucinations in CBS. Unfortunately, the clinical criteria for atypical CBS are ambiguous, potentially explaining the rarity of the diagnosis. In addition, certain features of atypical CBS may make the condition particularly prone to misdiagnosis. Case Presentation: We report a case of atypical CBS in a 67-year-old white male patient presenting with visual and auditory hallucinations that were improved by reassurance. Alongside this case presentation, we provide a review of atypical CBS cases in the literature to compare the diverse features of the syndrome. For this review, we included cases of atypical CBS or CBS plus within the past 20 years for which we could obtain the full text. Conclusion: Clearer guidelines for the diagnosis of atypical CBS and greater attention to the disorder could substantially improve the management of patients presenting with hallucinations. A broader differential diagnosis including atypical CBS for elderly patients with new-onset hallucinations could help clinicians and patients avoid unnecessary medical workup and treatment.
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Background Depressive disorders have a prevalence of 322 million people worldwide and are a leading cause of morbidity. These disorders can affect individuals of all ages and can present over time. Due to the diversity in the presentation of depressive disorders, vigilance towards depressive disorders can lead to more timely and effective treatment. Serotonin Selective Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) are the first lines of treatment for these disorders. Moreover, the United States Food and Drug Administration (FDA) issued a black-box warning for several antidepressants, stating an increased risk of suicidality in individuals under 25 years old. However, the placement of this black-box warning has been controversial. In this study, the authors aim to investigate if there is a relationship between the use of SSRI or SNRI on patients with newly diagnosed depressive disorder and hospital readmission due to suicide-related events. Methods For this retrospective cohort study, de-identified data were obtained from the HCA Healthcare database by searching for patients newly diagnosed with depressive disorders and started on SSRIs or SNRIs. Patient data were evaluated for readmissions due to suicide-related events within 90 days of discharge from the hospital and establishing their initial SSRI/SNRI prescription. Results After data was obtained and evaluated via statistical analysis, the variables with statistical significance were: age (p-value = 0.0164) and sex (p-value = 0.0150). These two were significantly associated with the rate of readmission: younger and male patients had an increased risk of readmission due to suicide-related events within 90 days of discharge after starting SSRI, or SNRI, to treat depressive disorders. Conclusion These results support the importance of monitoring patients started on SSRI or SNRI, with particularly careful consideration in depressed young male patients.
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Traumatic brain injury (TBI) is a leading cause of long-term disability and mortality in young adults. The devastating effects of TBI on emotion regulation, executive functioning, and cognition have been well-established, and recent research links TBI as a risk factor for neurodegenerative diseases such as Alzheimer's disease. Despite an increased focus on the long-term cognitive dysfunction associated with TBI, research into potential treatments has not yet generated consistent successful results in human subjects. Many foundational studies have analyzed the cellular and molecular events involved in the inflammatory and healing processes following TBI, enhancing our understanding of the mechanisms that may contribute to the progression of dementia and cognitive decline in these patients. In this review, we will discuss the emergent research on melatonin within the framework of neuroinflammation and oxidative stress resulting from TBI and possibly preventing further sequelae such as Alzheimer's disease. A literature review was conducted using standard search strategies to query the PubMed database. The following search terms were used with qualifiers of various combinations: TBI, traumatic brain injury, melatonin, treatment, dementia, Alzheimer's, cognition, and neurodegeneration. Selected studies included meta-analyses, literature reviews, and randomized controlled trials (RCT) that evaluated melatonin's role as a potential therapy to prevent post-TBI neurodegeneration, specifically the development of dementia and deficits in memory and cognition. Three independent reviewers assessed all articles for eligibility. After assessment for eligibility, 11 total studies were included. Much of the available data on melatonin in TBI has highlighted its significant neuroprotective and antiinflammatory effects, which can be significant in fighting against the neuroinflammatory processes indicated in neurodegeneration. In animal models, immunohistochemistry and histopathology have allowed researchers to study measures of cell injury such as inflammatory cytokines, edema, and markers of oxidative stress. Though the effects of melatonin in TBI appear to be mediated through mostly indirect mechanisms on inflammatory processes, some research has explored potential mechanisms that could be specific to melatonin. Animal model studies support that melatonin treatment after TBI significantly improves cognition and behavioral outcomes. However, clinical studies with human subjects are scarce. Beyond the apparent general antiinflammatory and antioxidant actions of melatonin, a review of the evidence identified some preliminary research that has suggested the significance of melatonin receptors specifically in TBI. While there is some evidence to suggest that melatonin is able to reduce post-TBI cognitive decline as measured by subject performance on memory tasks, there is a lack of longitudinal data on whether melatonin decreases the risk of developing dementia after TBI. Considering melatonin therapy's promising preclinical data, favorable safety profile, and accessibility, further studies are warranted to assess the effects of melatonin as a post-TBI therapy on human subjects.
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Description Neurocysticercosis, a parasitic infection of the central nervous system (CNS) caused by the Taenia solium cestode, presents clinically with a large and diverse spectrum of symptomatology, dependent upon lesion number, locale and ensuing inflammatory response. To this date, there are only two documented cases of psychosis presenting in patients with neurocysticercosis, both of which were published in India. This case presentation depicts the first documented case of Psychotic Disorder Due to Another Medical Condition: Neurocysticercosis in the United States. The authors postulate that the atypical presentation of the neuropsychiatric instability with the aberrant recurrence of neurocysticercosis is predominantly attributable to the parasitic infection itself, along with its resultant cyst formation and inflammatory response. Further research is necessary to expand upon our knowledge and understanding of the neuropsychiatric effects and optimal management of neurocysticercosis, as well as its possible recurrent nature.
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Alcohol use disorder (AUD), a chronic condition that affects many people worldwide, is characterized most commonly by a preoccupation with alcohol, an irresistible craving for or the inability to control the consumption of alcohol, and the marked resultant disturbance it bestows upon one's life. Although a difficult and time-consuming condition to attempt to treat, there are currently three FDA-approved medications for AUD, including naltrexone, acamprosate, and disulfiram. However, literature points towards another agent, gabapentin, that may be efficacious in preventing relapse symptoms and cravings with enhanced effectivity in reducing post-hospitalization alcohol consumption behaviors. In this paper, we discuss a case presentation and literature review demonstrating the role of gabapentin in treating AUD and symptoms associated with alcohol withdrawal, along with its potential use in relapse prevention.