Case report
In January 2020, a 31 years old Caucasian woman, with an underlying diagnosis of moderate intellectual disability and a recent diagnosis of Bipolar Affective Disorder in November 2019, was referred to her local Emergency Department (ED) by her GP requesting medical work-up to investigate thecause of new onsetimpaired mobility.
In the Emergency Department, she had blood investigationswhich showed an increase in WBC and Neutrophils (respectively 14.4mmol and 10.53mmol).Chest Radiograph was unremarkable. Urine dipstick revealed increased leukocytes anda Urinary Tract Infection (UTI) was diagnosed.
She presented with a history of new physical symptoms for around one week:
- Slurring of speech (usually her family are able to fully comprehend her)
- Not able to follow commands (usually compliant)
- Not able to use her hands (usually independent and able, for example, to feed herself)
- Tremor in upper and lower limbs
She was referred back to ED staff for further organic work-up and she was admitted to a medical ward.
One day following admission, she was referred to the Liaison Psychiatry team, and a full collateral history was obtained from her treating Intellectual Disability Consultant in the Community and her mother who is her next of kin. On the same day a CT brain was performed and nothing abnormal was detected.
Collateral history from mother/GP/ID Consultant
The patient had been living at home with her parents until 2016 until the age of 27. She was attending the local Intellectual Disability day services. She was first reviewed by an ID Consultant Psychiatrist in 2010 when she was diagnosed with Generalised Anxiety symptoms and prescribed Citalopram 20mg OD. Subsequently she made a full recovery and she remained on the same dose of Citalopram.
She was seen in a surgical ward in thehospital following a fall by the ID Consultant in February and March 2016. At her first review, patient’s mood was objectively anxious with separation anxiety in relation to mother in particular. There was no evidence of psychotic symptoms. On March,Citalopram 20mg od was stopped and Sertraline 50mg OD and a Diazepam 1mg BD was started.
In October 2017,her father died and her grandmother who she was very close to also died after two months. Following this, she was firstly initially admitted to a Respite Unitdue to an enhanced level of care required.
In April 2018 Sertraline was increased to 100mg OD because of anxiety. For the same reason, in July 2018 Alprazolam 0.25mg BD + 0.25mg BD PRN was started.
In August 2019, she started presenting with an increased level of anxiety manifesting in repetitive questioning, sometimes irritability, repeated requests for food, frequent requests to go to toilet and periods of urinary incontinence. This was very much out of character for her.
At this time, she starting attending another Intellectual Disability Consultant Psychiatrist linked with the community home. In August 2019, Alprazolam was discontinued and she was commenced on Lorazepam 1mg BD PRN. In September 2019, also due to anxiety, Mirtazapine 15mg nocte was commenced. In October 2019 Mirtazapine was increased to 45mg nocte and Lorazepam was decreased to 0.5mg BD PRN. She was still on Sertraline 100mg OD at this time.
In November 2019, there was deterioration in her mental state. She had early morning wakening, her mood appeared elated throughout day, she demonstrated incessant speech, very repetitive speech with echolalia and she could not sit still for long periods withouthyperactivity. Her symptoms were consistent with an episode of hypomania and she was diagnosed of Bipolar Affective Disorder.Sertraline was discontinued and Quetiapine was started and gradually titrated up to 50mg mane + 75mg nocte.
There was a slight reduction in her hypomanic symptoms, however she still presented with pressured speech, flight of ideas and repetitive behaviours. Her Mirtazapine was reduced to 30mg nocte. Olanzapine 5mg OD + Olanzapine 5mg BD PRN was commenced.
After around five days, her physical condition deteriorated. Her mobility deteriorated and she became more withdrawn according to her mother.At the same time, she was diagnosed with bronchitis by her GP. She was prescribed the antibiotic Doxycyline and it was initially thought that the impairment of the mobility was a side effect of the antibiotic.
At review in January 2020 she appeared mildly elated. She was less talkative, appeared calmer, was less repetitive and her responses appeared more rational although grandiose in manner.
It was mentioned that she hadtwo dosesof PRN Olanzapine 5mg which appeared effective to settle her mood.Olanzapine was increased to 5mg BD.Quetiapine reduced to 25mg mane + 75mg nocte.Mirtazapine 30mg nocte and Lorazepam 0.5mg BD PRN were left unchanged.
Unfortunately,she continued experiencing low grade fever, vomiting, symptoms of UTI. Furthermore, she was less mobile and she started using a wheelchair and there was an increase in behavioural problems.Therefore, GP directed her to the local ED for further investigation and management. Subsequently she was admitted to the medical ward as mentioned above.
Course in Hospital in January 2020
At Liaison Psychiatry review, the morning following her medical in-patient admission,she presented with symptoms suggestive of neuroleptic malignant syndrome (NMS): fever (38.2°C), increased muscular tone bilaterally in upper and lower limbswith cogwheel phenomenon. She had in atremor in her upper and lower limbs, reduced mobility, dysphagia, slurred speech, tachycardia (130 bpm), labile blood pressure(140/102 –126/80), increased CK (1033mmol), increased WBC (14.4mmol).
Collateral history was taken from her carer and her mother. They reported that patient started experiencing physical symptoms and also more sociallywithdrawn compared to her usual baseline soon after Olanzapine 5mg once daily was started in December 2019. Her symptoms subsequently deteriorated in January 2020 after Olanzapine was increased to 5mg BD. At the time, she was also on Quetiapine 25mg once daily + 75mg nocte and Mirtazapine 30mg nocte.
It is relevant to mention that when she was on higher doses of both Quetiapine and Mirtazapine there were no concerns in relation to her physical health and that the symptoms suggestive of NMS started when Olanzapine was increased.
Upon Liaison Psychiatry review the first day of her admission, her Olanzapine and Quetiapine were both discontinued and she was commenced on Diazepam 1mg TDS and it was increased to 2mg TDS the following day. She was also commenced on Lorazepam 0.5mg QDS PRN but it was not necessary to give her this medication at any stage during the course of her medical admission. The day after, Mirtazapine was reduced to 15mg nocte.
During the course of her medical admission she was regularly reviewed by the Liaison Psychiatry team, her mental state appeared stable.
Her physical condition improved during her admission. CK and WBC decreased respectively to 499 mmol and 9.8 mmol after one week.
On discharge after a 10 day admission, patient presented with objectively euthymic mood, no evidence of distress, no agitation. Nilpsychotic symptoms were elicited. She presented brighter, appropriate in her conversation and appeared at baseline; with no pyrexia, normal Blood pressureand heart rate and, normal muscle tone in all four limbs.She was discharged on Diazepam 2mg TDS and Mirtazapine 15mg nocte.Her mother reported that she was back to her usual premorbid baseline.
The patient was medically admitted again to University Hospital Waterford twelve days after her previous dischargefor treatment of a UTI. Her CK level was 100 mmol on admission.She was regularly reviewed by the Liaison Psychiatry team and she always presented in a stable mental state and without features suggestive of NMS on this 2nd admission. There was no evidence of psychomotor agitation. Her speech was repetitive but comprehensible although it remained mildlyslurred. Her mood was euthymic with reactive affect. Nil psychotic symptoms were elicited. She was alert and aware of her surroundings.She was discharged after one week on Diazepam 2mg TDS and Mirtazapine 15mg nocte. She is now being treated by the Learning Disability Team in the Community. She has remained physically well since her last discharge from hospital six (so far) months ago.
At the time this case report is written (November 2020), the patient has remained stable on a mental state view point and she is maintained on Mirtazapine 15mg nocte, Valproate Chrono 500mg BD, Depo-Provera 150mg IM every 12 weeks (long acting contraception), Clonazepam 0.5mg PRN max BD.