Cases That Test Your Skills

A perplexing case of altered mental status

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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?



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CASE: Agitated and paranoid

Mr. E, age 55, presents to the emergency department (ED) with a 2-week history of altered mental status (AMS). His wife reports, “He was normal one day and the next day he was not.” Mr. E also presents with sleep disturbance, decreased appetite and speech, and a 20-lb weight loss. His family reports no recent stressors or head trauma. Mr. E is agitated in the ED and receives a single dose of IV haloperidol, 5 mg. He exhibits paranoia and is afraid to get a CT scan. The medical team attempts a lumbar puncture (LP), but Mr. E does not cooperate.

His laboratory values are: potassium, 3.0 mEq/L; creatinine, 1.60 mg/dL; calcium, 10.6 mg/dL; thyroid-stimulating hormone, 0.177 IU/L; vitamin B12, >1500 pg/mL; folate, >20 ng/mL; and creatine kinase, 281 U/L. Urine drug screen is positive for benzodiazepines and opiates, neither of which was prescribed, and blood alcohol is negative.

Mr. E is admitted for further workup of AMS. His daughter-in-law states that Mr. E is an alcoholic and she is concerned that he may have mixed drugs and alcohol. The medical service starts Mr. E on empiric antimicrobials—vancomycin, ceftriaxone, and acyclovir—because of his AMS, and performs an LP to rule out intracranial pathology. His LP results are unremarkable.

Mr. E appears to be confused during psychiatric evaluation. He requests to be “hypnotized on a helicopter to find out what is wrong with me.” His wife states that Mr. E drank vodka daily but decreased his alcohol consumption after surgery 5 months ago. Before his current admission, he was drinking approximately half a glass of vodka every few days, according to his wife. Mr. E says he has no prior psychiatric admissions. During the mental status exam, his eye contact is poor, with latency of response to questions, thought blocking, and psychomotor retardation. He is alert, oriented to time, place, and person, and cooperative. He cannot concentrate or focus during the interview. He denies suicidal or homicidal ideation.

The authors’ observations

Mr. E appeared to be delirious, as evidenced by the sudden onset of waxing and waning changes in consciousness, attention deficits, and cognition. He also had a history of daily alcohol use and decreased his alcohol intake after a surgery 5 months ago, which puts him at risk for Wernicke’s encephalopathy.1-3 The type of surgery and whether he received adequate thiamine supplementation at that time was unclear. Because Mr. E is older, he has a higher risk of mortality and morbidity from delirium.4,5 We started Mr. E on quetiapine, 50 mg/d, for delirium and an IV lorazepam taper, starting at 2 mg every 8 hours, because the extent of his alcohol and benzodiazepine use was unclear—we weren’t sure how forthcoming he was about his alcohol use. He received IV thiamine supplementation followed by oral thiamine, 100 mg/d.

The authors’ recommendations

We requested a neurology consult, EEG, CSF cultures, and brain MRI (Table 1).6 EEG, chest radiography, thyroid scan, and CT scan were normal and MRI showed no acute intracranial process. However, there was a redemonstration of increased T1 signal seen within the bilateral basal ganglia and relative diminutive appearance to the bilateral mamillary bodies, which suggests possible liver disease and/or alcohol abuse. These findings were unchanged from an MRI Mr. E received 10 years ago, were consistent with his history of alcohol abuse, and may indicate an underlying predisposition to delirium. A CT scan of the abdomen showed hepatic cirrhosis with prominent, tortuous vessels of the upper abdomen, subtle ill-defined hypodensity of the anterior aspect of the liver, and an enlarged spleen.

Mr. E’s mental functioning did not improve with quetiapine and lorazepam. Further evaluation revealed a negative human immunodeficiency virus test and normal heavy metals, ammonia, ceruloplasmin, and thiamine. We suspected limbic encephalitis because of Mr. E’s memory problems and behavioral and psychiatric manifestations,7 but CSF was unremarkable and limbic encephalitis workup of CSF and paraneoplastic antibody panel were negative.

Mr. E’s primary care physician stated that at an appointment 1 month ago, Mr. E was alert, oriented, and conversational with normal thought processing. At that time he had presented with rectal bleeding, occult blood in his stool, and an unintentional 25-lb weight loss over 2 months. It was not clear if his weight loss was caused by poor nutrition—which is common among chronic alcoholics—or an occult disease process.

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