Transcript The Pediatric Patient - Virginia Commonwealth University

Psychiatric Aspects of
Non-HIV Infectious Diseases
Robert K. Schneider, MD
Michael J. Robinson, MD
James L. Levenson, MD
Why Now?
• Global Society
– Increased Travel
– Increased Immigration/Emigration
• Broader Medical Management
– HIV
– Malignancies
– Transplantation
• People living longer
Infectious Disease Syndromes
Chapter 52
Robert K. Schneider
James L. Levenson
Risk Groups
Immune Status
Demographics
Risk Groups
• Immune Status
– Elderly
– Chronic Disease
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HIV
Malignancy
Transplant
Diseases where immunosuppressants are used
– (ie SLE, Psoriasis, IPF)
– Substance Abuse
Risk Groups
• Demographics
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Children
Recreational Activities
Occupation
Region of origin or residence
Travel
Assessment
• Consider infectious causes when patient is in the
risk group
– Immune Status
– Demographics
• Activate an appropriate differential diagnosis
• Know the best tests to evaluate these patients
• Know the best treatments for these conditions
Case One
Postpartum Woman
with Psychosis
Postpartum Woman with Psychosis
• 34 yo woman 4 weeks postpartum
• 3 week history of paranoid ideation and
auditory hallucinations
• Other points on history?
Postpartum Woman with Psychosis
• Recently emigrated from Mexico
• The family reports seizure disorder since
age 3
• Several family members have seizures
• Family reports no substance abuse
What’s the differential diagnosis?
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Postpartum psychosis
Ictal or interictal psychosis
Substance Abuse
Malignancy
Infectious causes
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Brain Abscess
Toxoplasmosis
Neurocysticerosis
Tuberculosis
Postpartum Woman from Mexico
• EEG: “normal”
• Urine Drug Screen: Negative
(collateral family hx supports this)
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CXR: normal
CBC: 7,000: 60 neut; 5 eos; 30 lymph; 5 mono
Hct: 40%
Biochemical Profile: WNL
HIV: negative
Postpartum Woman from Mexico
• Head CT with and without contrast:
multiple cystic and calcified lesions
• CSF:
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24 WBC all lymphs
Protein and Glucose: wnl
Stains: negative
Cultures: pending
• Serology:
– Pending
Differential Diagnosis:Toxoplasmosis
• Exceedingly common in general population
• Disease occurs only in
immunocompromized host
• Most common treatable cerebral lesion in HIV
• CT: ring enhancing lesions
• CSF: pleocytosis
• Serology: antibody positive 67%
Differential Diagnosis:Tuberculosis
• 15% extrapulomanry
• Most CNS TB is parameningeal
– Cerebral TB is very rare
• CT scan: negative or meningeal granulomas
• CSF: almost always reactive
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Depressed glucose
Increased WBC
Markedly elevated protein
Stains positive 25%/Cultures positive 75%
Differential Diagnosis:Brain Abscess
• Patient usually with evidence of systemic
infection
• History of IVDA, Valvular heart disease or
recent neurosurgery
• CSF: virtually always positive, particularly
on stains showing organisms
Neurocysticercosis
• The “Pork Tapeworm”
• Caused by the larval form of Taenia solium
• Most widely disseminated neuroparasitosis
• CNS is the most frequently affected organ (92%)
• Most common cause of seizures in endemic
areas
• Endemic in Latin America, sub-Saharan Africa,
India and China
Classification
• Inactive disease
• Active disease
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Parenchymal
Ventricular
Subarachnoid
Spinal and ocular
Neuroimaging
• CT scan is the primary means of diagnosis
• Most commonly reveals inactive disease
– <1 cm calcifications
– Hydrocephalus is evident secondary to obstructive
intraventricular disease
• Active Disease
– Ring enhancing cystic lesions
– Pathognomonic scolex is sometimes seen in the cyst
– Meningeal disease is hard to detect on CT
How good is serology in NCC?
• CDC immunoblot assay
• Acknowledged as immunodiagnositic by:
– World Health Organization
– Pan American Health Organization
• 100% specific
• Sensitivity varies:
– Multiple lesions: 90%
– Single enhancing parenchymal cysts: <50%
– Clinically defined patients with calcified cysts: 70%
What are the Psychiatric
Aspects of NCC?
• Depression: >50% in outpatient setting
• Psychosis: 14% in outpatient, probably
higher at presentation (inpatient)
• Delirium often present at presentation
• Cognitive decline and symptoms of
hydrocephalus
• Headache is common but nonspecific
What’s the best treatment?
• If inactive disease, no treatment except for
the seizure disorder.
• If active disease, corticosteroids and
praziquantel is the main stay.
• However, praziquantel is toxic and recent
RCT suggest no benefit over symptomatic
treatment.
• In hydrcephalus (usually inactive, chronic
NCC) surgically shunting is indicated.
What areas of the US is NCC rising?
• Prevalence in US is increasing, especially in
areas with high immigrant populations
– (eg Texas, California)
• Most cases occur among Latin American
immigrants
• Local transmission is probably higher than
expected
Does NCC occur in travelers?
• Yes
• Can occur with only brief contact
• Risk increases the longer the contact
Cysticercosis surveillance: Locally acquired and travel-rated infections and detection of
intestinal tapeworm carriers in Los Angeles Count. Sorvillo FJ, Waterman SH, Richards
FO, Schantz PM. Am J Trop Med Hyg. 1992;47(3),365-371.
Are you safe if you don’t eat pork?
• No
• Most transmission occurs from eating food
that is fertilized with pork or human waste
• Also carriers that are food handlers can
transmit T. solium
• NCC occurred in an Orthodox Jewish
community in New York City. Infection
was secondary to food handlers who were
carriers of T solium
Neurocysticerosis in an Ortodox Jewish Community in New York city. Schantz PM,
Moore AC, Munoz JL, et al. NEJM 1992;327:692-5
Wrap up and questions ?
Case Two
The Pediatric Patient
The Case
• LR is a 5 year old girl who presents with the
following complaints from her parents:
• HPI:
– “she has recently started to obsess about
everything”
– “she is constantly counting to four”
– “everything has to be in its certain place or she
gets really upset”
The Case
– “she repeatedly blinks” and “jerks her head the the
side”
– “she later started to do things with her voice”
– Other associated behavior complaints
• Recent PMHx:
– sick with a fever on and off for the last few months
– CXR - normal
– No other investigations have been performed
The Case
• Past Psych Hx:
– None; No emotional, behavioral, or school
problems noted
• Past Medical Hx:
– early childhood recurrent otitis media, not
requiring myringotomy tubes or prophylactic
antibiotics
The Case
• Family hx:
– first of 2 children; healthy younger brother
– maternal hx of depression responsive to antidepressant
medications
– maternal grandmother with a hx of trichotillomania
– paternal hx of vocal tics as a child
– No OCD, No Sydenham’s chorea, No Rheumatic fever
Differential Diagnosis
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OCD
ADHD
Separation Anxiety
PANDAS
Sydenham’s Chorea
Transient Tic Disorder
Tourette’s Disorder / Chronic Motor or Vocal Tic
Disorder
Initial Work-Up?
• Throat Culture Positive for GABHS
• Anything else?
– MRI?
– D8/17?
– Anti-GABHS antibody titres? Which ones?
PANDAS
• PANDAS = ?
• Inclusionary Criteria:
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Presence of OCD and/or tic disorder
Pediatric onset
Episodic course of symptom severity
Association with GABHS infection
Association with neurological abnormalities
PANDAS
• Proposed Pathogenesis:
– Pathogen + Susceptible Host 
Immune Response  Sydenham’s
Chorea or PANDAS
PANDAS
• Association with GABHS?
– Positive throat culture
• Is a positive throat culture enough to demonstrate
recent GABHS infection?
– Elevated ASO and/or AntiDNase-B titres
• Are elevated titres enough to demonstrate recent
GABHS infection?
– Can a child have a relapse of symptoms without
evidence for a recent GABHS infection?
PANDAS
• Any other investigations?
– Is an MRI warranted?
– What is the significance of B-lymphocyte
antigen D8/17? Should we test for it?
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Time (Months)
C-YBOCS Ratings
IVIG Treatment
Tourette Syndrome Unified Rating Scale
AntiDNAse-B titres
Antibody Titre (IU/ml)
Ratings
Example Relationship Between AntiDNAse-B titres and Ratings of
OCD and Tourette's
PANDAS - Treatment Options
• Antibiotics?
– Acute treatment and/or prophylaxis?
• Plasma exchange/Plasmaphoresis
• Intravenous immunoglobulin
Discussion & Questions
Case Three
Tick-bitten Hikers
• 35 year-old woman, hiked Appalachian
Trail
• One week: flu-like symptoms, large rash
on groin, facial palsy, Lyme serology
negative
• Two months: headache, stiff neck, arm
numb and burning
• One year: depression, fatigue, forgetful
• 36-year-old man, hiked Glacier National
Park
• One week: flu-like symptoms,
parethesias in hands and feet
• Two months: headache, stiff neck,
fatigue, Lyme serology positive
• One year: depression, fatigue, diffuse
myalgia
Lyme Disease
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Caused by spirochete, Borrelia burgdorfei
Transmitted by deer ticks (<5% risk)
Over 10,000 cases/year reported in U.S.
Over 90% from 8 states (CT, RI, NY, NJ,
PA, MD, WI, MN)
The Deer Tick
Incidence of Lyme per 100,000
Disease Onset (One week)
• Erythema migrans, >90%
• Central clearing, <40%
Erythema Migrans
Acute Disseminated Disease
(First month)
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Fatigue, 54%
Myalgia/arthralgia, 44%
Headache, 42%
Fever/chills, 39%
Stiff neck, 35%
Subacute Disease (Months)
• Arthritis, oligoarticular, most often knee, 60%
• Secondary skin lesions, 50%
• Neurological, 15%
– Cranial neuropathy, most often VII
– Meningitis
– Painful radiculopathy
• Carditis (conduction disturbance), 5-10%
Chronic Disease (Years)
• Dermatitis
• Arthritis
• Neurological
– Mild sensory radiculopathy
– Cognitive dysfunction
– Depression
Chronic Neuroborreliosis –
Diagnostic Tests
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CSF abnormal (>50%):  protein, Ab positive
MRI abnormal (25%): White matter lesions
EEG normal
Neuropsych testing abnormal
Lyme disease is a clinical diagnosis
Serology can support
but not make diagnosis
Serology
• Two step
• Initial: ELISA (or IPA)
• If positive: Western blot
Serology Limitations
• False negative in early infection
• False negative after early antibiotics
• False positive in other infections,
autoimmune diseases
• True positive uncorrelated with time or
activity
Treatment
• Acute disease:
– oral doxycycline or amoxicillin, 2-4 weeks
• Neuroborreliosis:
– IV ceftriaxone, 2-4 weeks
• Complete recovery is the rule
Prevention
• Prophylaxis not recommended after tick bite
• Cover up and DEET
• Vaccine effective
– 50-70% first year
– 75-90% second year
• 35-year-old woman, hiked Appalachian
Trail
• One week: flu-like symptoms, large rash
on groin, facial palsy
• Two months: headache, stiff neck, arm
numb and burning
• One year: depression, fatigue, forgetful
• 36-year-old man, hiked Glacier National
Park
• One week: flu-like symptoms, parethesias
in hands and feet
• Two months: headache, stiff neck,
fatigue, Lyme serology positive
• One year: depression, fatigue, diffuse
myalgia
Differential Diagnosis
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Fibromyalgia
Chronic fatigue syndrome
Other infections
Somatoform disorders
Depression
Autoimmune diseases
Multiple sclerosis
Consequences of Overdiagnosis &
Overtreatment
• Somatization
• Invalidism
• Antibiotic side effects
“Lyme colitis” (Clostridia enteropathy)
Questions?