Case Diagnosis: Encephalopathy due to underlying psychiatric condition
45 year old female with history of bipolar disorder who was hospitalized after experiencing a “seizure”. On admission she was awake, but minimally responsive. An extensive neurological workup was unremarkable. Medication interventions, including Lorazepam challenge, solumedrol course, and IVIG did not improve her condition. She was diagnosed with encephalopathy of unclear etiology and one month after admission she was transferred to inpatient rehabilitation. While in rehabilitation she initially made limited functional improvements, had multiple medical setbacks, and continued to be minimally responsive beyond moaning with continued restlessness. Her behavior was regulated with clonazepam, valproic acid, propranolol, escitalopram, mirtazapine and quetiapine. Eventually, with psychiatric input, her medication was adjusted by switching her SSRI to venlafaxine, and neuroleptic to olanzapine. With additional dose titration she made significant cognitive and functional improvement and was eventually discharged home with her parents.
Patient's diagnosis of encephalopathy of uncertain etiology was initially thought to be autoimmune or secondary to medication overdose. She had multiple treatment regimens with little improvement. Her underlying psychiatric condition was found to be the presumed cause of her condition, likely a combination of bipolar disorder with major depression. With modification of her psychotropic regimen she went from near catatonia on admission to being discharged three months later at a supervision level.