A perplexing case of altered mental status
Mr. E, age 55, has a 2-week history of altered mental status, sleep disturbance, and decreased appetite and speech. Medical workup does not reveal an underlying cause. How would you proceed?
It is puzzling whether Mr. E’s AMS was a first psychotic break, a result of drug and alcohol use, rapidly progressing dementia, or another neurologic problem that we have not identified. Our tentative diagnosis was Wernicke-Korsakoff syndrome because of his history of alcohol use and imaging findings.
Although we used a multidisciplinary team approach that included psychiatry, internal medicine, neurology, neuropsychology, and an aggressive and thorough workup, we could not establish a definitive diagnosis. Unsolved cases such as this can leave patients and clinicians frustrated and may lead to unfavorable outcomes. Additional resources such as a telephone call after the first missed appointment may have been warranted.
Table 2
Mr. E’s clinical course
| Symptoms | Treatment | |
|---|---|---|
| First ED visit | Agitation Confusion Sleep disturbance Decreased appetite and speech 20-lb weight loss | Empiric antimicrobials for possible meningitis Haloperidol for agitation Quetiapine for delirium Lorazepam taper Thiamine supplementation |
| Second ED visit | Violent behavior Worsening paranoia Responding to internal stimuli Mr. E believes he has 2 wives, but the wife in the room is not the real one, which suggests possible Capgras syndrome Cognitive deficits on mental status exam | Switch from ceftriaxone to ciprofloxacin for Pseudomonas aeruginosa Switch from quetiapine to olanzapine |
| ED: emergency department | ||
Related Resources
- Kaufman DM. Clinical neurology for psychiatrists. 6th ed. Philadelphia, PA: Saunders Elsevier; 2007.
- Sidhu KS, Balon R, Ajluni V, et al. Standard EEG and the difficult-to-assess mental status. Ann Clin Psychiatry. 2009;21(2):103-108.
Drug Brand Names
- Acyclovir • Zovirax
- Ceftriaxone • Rocephin
- Ciprofloxacin • Cipro
- Haloperidol • Haldol
- Lorazepam • Ativan
- Olanzapine • Zyprexa
- Quetiapine • Seroquel
- Thiamine • Betaxin
- Vancomycin • Vancocin
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
