Psychiatric Aspects of Non-HIV Infectious Diseases

1. Psychiatric Aspects ofNon-HIV Infectious Diseases Robert K. Schneider, MD Michael J. Robinson, MD James L. Levenson, MD

2. Why Now? • Global Society • Increased Travel • Increased Immigration/Emigration • Broader Medical Management • HIV • Malignancies • Transplantation • People living longer

3. Infectious Disease SyndromesChapter 52Robert K. SchneiderJames L. Levenson

4. Risk Groups Immune Status Demographics

5. Risk Groups • Immune Status • Elderly • Chronic Disease • HIV • Malignancy • Transplant • Diseases where immunosuppressants are used • (ie SLE, Psoriasis, IPF) • Substance Abuse

6. Risk Groups • Demographics • Children • Recreational Activities • Occupation • Region of origin or residence • Travel

7. 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

8. Case One Postpartum Woman with Psychosis

9. Postpartum Woman with Psychosis • 34 yo woman 4 weeks postpartum • 3 week history of paranoid ideation and auditory hallucinations • Other points on history?

10. 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

11. What’s the differential diagnosis? • Postpartum psychosis • Ictal or interictal psychosis • Substance Abuse • Malignancy • Infectious causes • Brain Abscess • Toxoplasmosis • Neurocysticerosis • Tuberculosis

12. Postpartum Woman from Mexico • EEG: “normal” • Urine Drug Screen: Negative (collateral family hx supports this) • CXR: normal • CBC: 7,000: 60 neut; 5 eos; 30 lymph; 5 mono • Hct: 40% • Biochemical Profile: WNL • HIV: negative

13. Postpartum Woman from Mexico • Head CT with and without contrast: multiple cystic and calcified lesions • CSF: • 24 WBC all lymphs • Protein and Glucose: wnl • Stains: negative • Cultures: pending • Serology: • Pending

15. 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%

16. 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 • Depressed glucose • Increased WBC • Markedly elevated protein • Stains positive 25%/Cultures positive 75%

17. 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

18. 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

22. Classification • Inactive disease • Active disease • Parenchymal • Ventricular • Subarachnoid • Spinal and ocular

23. 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

25. 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%

26. 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

27. 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.

28. 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

29. 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.

30. 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

31. Wrap up and questions ?

32. Case Two The Pediatric Patient

33. 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”

34. 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

35. 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

36. 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

37. Differential Diagnosis • OCD • ADHD • Separation Anxiety • PANDAS • Sydenham’s Chorea • Transient Tic Disorder • Tourette’s Disorder / Chronic Motor or Vocal Tic Disorder

38. Initial Work-Up? • Throat Culture Positive for GABHS • Anything else? • MRI? • D8/17? • Anti-GABHS antibody titres? Which ones?

39. PANDAS • PANDAS = ? • Inclusionary Criteria: • Presence of OCD and/or tic disorder • Pediatric onset • Episodic course of symptom severity • Association with GABHS infection • Association with neurological abnormalities

40. PANDAS • Proposed Pathogenesis: • Pathogen + Susceptible Host  Immune Response  Sydenham’s Chorea or PANDAS

41. 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?

42. PANDAS • Any other investigations? • Is an MRI warranted? • What is the significance of B-lymphocyte antigen D8/17? Should we test for it?

43. IVIG Treatment

44. PANDAS - Treatment Options • Antibiotics? • Acute treatment and/or prophylaxis? • Plasma exchange/Plasmaphoresis • Intravenous immunoglobulin

45. Discussion & Questions

46. Case Three Tick-bitten Hikers

47. 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

48. 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

49. Lyme Disease • 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)

50. The Deer Tick