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(150) Tuberculosis Psychosis: Tuberculosis Meningoencephalitis Presenting as Major Depressive Disorder with Psychotic Features


Authors:

Sarah Slabaugh, DO – PGY-II, John Peter Smith Hospital

Aisha Gillan – Medical Student - Year 4, University of North Texas Health Science Center

Zachary Herrmann, DO – PGY-III, John Peter Smith Hospital

Dustin DeMoss, DO, FAPA – Associate Program Director/Assistant Clinical Professor, John Peter Smith Hospital Psychiatry Residency Program


Co-Authors:

Presenting Author: Sarah Slabaugh, DO, John Peter Smith Hospital
Co-Author: Aisha Gillan, University of North Texas Health Science Center
Co-Author: Zachary Herrmann, DO, John Peter Smith Hospital
Co-Author: Dustin DeMoss, DO, FAPA, John Peter Smith Hospital Psychiatry Residency Program

Abstract:

Background: The prominence of autoimmune encephalitis presenting with psychiatric symptoms is well-described in literature (Kayser, 2014). Primary psychiatric presentation of meningoencephalitis is uncommon (Mouhadi, 2017). This report examines a case of tuberculosis meningoencephalitis whose chief complaint was psychiatric. This case also highlights how cultural and language barriers can affect complex clinical presentations.


Case:
46-year-old Spanish-speaking Mexican male with history of polychondritis on immunosuppression treatment and no past psychiatric history presented involuntarily to the psychiatric emergency room after being found walking naked in traffic. The patient’s mental status exam was significant for flat affect, command auditory hallucinations, and suicidal and homicidal ideation. Patient’s medical work-up was negative and he was admitted to psychiatry. He was diagnosed with major depressive disorder with psychotic features and was discharged 18 days later after stabilizing on citalopram, mirtazapine, and risperidone. Over the following 6 weeks he presented to the emergency room three times and was eventually admitted for altered mental status. Magnetic resonance imaging revealed multifocal areas of enhancement of cortical and subcortical structures as well as dural/leptomeningeal enhancements over the bilateral frontoparietal convexities. Cerebral spinal fluid revealed elevated adenosine deaminase level and diagnosis of tuberculosis meningoencephalitis was made. Psychotic symptoms improved with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) treatment.


Discussion:
Rarely does encephalitis present with psychiatric symptoms alone (Cancino Botello, 2016). A primary medical etiology should be considered in a patient with no previous psychiatric history, new onset hallucinations, and negative urine drug screen and workup should include infectious and autoimmune processes (Laher, 2018). Diagnosis and treatment were delayed due to language and cultural barriers and this illustrates the need to prioritize thorough medical workup in cross-cultural patients as culture is widely thought to influence the form, content, and extent of psychiatric symptoms that are experienced in the immigrant population (Weisman, 2000).


Conclusion:
This case illustrates the importance of prioritizing a medical differential diagnosis of a first-time psychiatric presentation in a non-English speaking adult. This is especially true when there is an underlying medical illness and cultural barriers may be complicating the presentation.

References:

Cancino Botello, M. C., et al. Psychiatric symptoms as onset of anti-NMDAR encephalitis. European Psychiatry.
2016; 33:S525.

Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. Schizophrenia Research. 2014; 176(1):36–40.

Laher AE, et al. First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question. American Journal of Emergency Medicine. 2018; 36(11):2068-2075.

Mouhadi K, Boulahri T, Rouimi A. Tuberculosis meningoencephalitis revealed by psychiatric disorders: about a case. Pan African Medical Journal. 2017; 27(206).

Wesiman AG, et al. A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia. Schizophrenia Bulletin. 2000; 26(4);817-24.


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