Behavior disturbances after corticotherapy in a patient with uncommom neurological manifestation of Behcet Syndrome and the role of the consultation liaison psychiatry

Abstracts

A Interconsulta Psiquiátrica (IP) trata-se do estudo da relação entre a psiquiatria e todas as outras áreas dos conhecimentos do processo saúde-doença, visando, sob uma perspectiva biopsicossocial, atender sua demanda clínica (prestação da assistência ao paciente) e institucional (relacionada aos serviços). É descrito o caso de uma paciente que apresentou rara manifestação fisiopatológica da Síndrome de Behçet e que evoluiu com transtorno psiquiátrico após a instituição de terapêutica com corticoesteróides. Apesar da remissão dos sintomas mentais e comportamentais com tratamento psicofarmacológico de curta duração, a evolução do quadro demandou a reintrodução de corticoterapia, com recrudescência de quadro psiquiátrico e necessidade de instituição de tratamento de manutenção para seu manejo. Além de ilustrativo, no sentido de discutir uma rara condição clínica, o caso descrito exemplifica os benefícios da atuação conjunta e planejada entre psiquiatras e outros profissionais na assistência integral ao paciente.

Psicologia aspectos psiquiátricos; transtorno mental orgânico; Síndrome de Behçet

RELATO DE CASO

Psychiatric disturbances after corticotherapy in a patient with uncommon neurological manifestation of Behçet's Syndrome and the role of the consultation liaison psychiatry

Amilton Santos Júnior^I; Lucas Francisco Botequio Mella^II; Egberto Ribeiro Turato^III; Neury José Botega^IV

^IPsychiatrist with expertise in Psychotherapy, DPMP-FCM-UNICAMP

^IIPGY1 in Psychiatry, DPMP-FCM-UNICAMP

^IIIAssociate Professor of Psychiatry, DPMP-FCM-UNICAMP

^IVFull Professor of Psychiatry, DPMP-FCM-UNICAMP

Corresponding author

ABSTRACT

Consultation Liaison Psychiatry studies the relationship between psychiatry and all other areas of knowledge of the health-disease process and intends to propose solutions, under a biopsychosocial perspective, to the clinical (assistant) or institutional (service-related) problems. It is described the case of a patient who presented unusual pathophysiologic manifestation of the Behcet's syndrome and also developed mental disorder after the pharmacological treatment with corticosteroids. Despite the remission of mental and behavioral symptoms with psychopharmacological treatment of short duration, her clinical outcome made it need the reintroduction of corticotherapy, with recrudescence of the psychiatric disorder and the need for maintenance treatment to assure its management. Besides illustrating a rare clinical condition, the case described exemplifies the benefits of joint and planned actions between psychiatrists and other professionals involved in an individual assistance at the hospital ward.

Key words (MeSH): Psychology Psychiatric aspects - Organic Mental Disorders – Behcet Syndrome.

Introduction

Consultation Liaison Psychiatry (CLP) is a discipline that studies the phenomena involved in the relations between psychiatry and all other knowledge areas of the health-disease process, as well as proposes therapies to clinical (patient care) or institutional (service demand) issues. Based on a biopsychosocial perspective of illness, CLP seeks a more integral and efficacious approach to people with both mental disorders and physical comorbidities.¹ From this perspective, an interdisciplinary and cooperative work encompasses a joint therapeutic project between mental health professionals and colleagues from other areas of health knowledge to the care of medical intercurrences related to mental and behavioral disorders.

The clinical report of a patient presenting Behçet's Syndrome, an uncommon nosological condition, and who developed psychiatric symptoms after pharmacological treatment, is described. The role of CLP during acute management of psychopathological symptoms in patients with clinical comorbidity is also emphasized.

Behçet's Syndrome is characterized by a multisystemic inflammatory condition, most commonly presenting recurrent oral and genital ulcers and relapsing ophthalmologic inflammation.^2-3 There are no specific tests for its diagnosis, which is based on clinical criteria.^2-4 The involvement of the central nervous system was first recognized in 1941, with autopsy findings being described only in 1944.² The frequency of this involvement varies from 15 to 25% in the majority of studies,^2,5-8 although the pseudotumoral Neuro-Behçet presentation is a very rare condition.^2,9-10 Neurological presentations and clinical outcomes are variable. Differential diagnosis shall consider multiple sclerosis, infections, vascular diseases and tumors. Treatment requires pulse therapy of immunosuppressive drugs, most often steroids.

Neuropsychiatric symptoms are commonly reported in several clinical conditions that require therapy with corticosteroids, particularly if used in high doses. They may also occur during withdrawal of medication. Reactions may include anxiety, insomnia, manic/depressive episodes, confusion, hallucinations, paranoid symptoms, psychosis, catatonia and delirium.¹¹ Treatment should include, simultaneously, a pharmacological approach specific to the psychopathological syndromic condition and a review of the dose and duration of corticosteroid therapy.

Clinical case description

A 47 year-old female with Behçet's Syndrome was under follow-up consultations in the Clinical Hospital of University of Campinas (State of Sao Paulo, Brazil) since the beginning of 2002. She initially developed polyarthralgia, oral and genital ulcers, and also subcapsular cataract, vitreous haze and retinal vascular atrophy, with persistent bilateral decrease of visual acuity. Her clinical presentation evolved to a sudden onset of holocranial headache, accompanied by fatigue, photophobia, right eyelid ptosis and mild paresis of the left arm and the facial innervation area. Computed tomography of the skull evidenced a thalamic lesion of 2 X 2 cm, with contrast uptake and causing mass effect. Magnetic resonance imaging evidenced ipsilateral extension of the lesion to the lentiform nucleus, subthalamic area, cerebral peduncle and subcortical white matter, compressing the third ventricle and deviating the midline.

A tumor in the central nervous system was suggested as the first diagnostic hypothesis. However, after a stereotactic brain biopsy, areas of gliosis, with gemistocytic astrocytes, were found, which indicated that the injury was caused by an inflammatory process without signs of tumor or vasculitis. Pseudotumoral neuro-Behçet was diagnosed - an unusual presentation of this syndrome.

Corticosteroid therapy was initiated and her neurological condition moved into complete remission, with a normal new magnetic resonance imaging after eight weeks of treatment. However, the patient began to present psychomotor agitation, aggressiveness, sexual disinhibition, verbosity, memory loss, decreased need for sleep and visual hallucinations (hypnagogic and Lilliputian). The psychiatric condition lasted about eight weeks, remitting after temporary replacement of corticotherapy by cyclophosphamide and symptomatic treatment with neuroleptics.

The patient exhibited no further inflammatory activity with the regular use of low doses of prednisone (5 mg every two days) until April 2007, when bilateral reactivation outbreaks of anterior uveitis were found, which prompted the rheumatology team to establish a new cycle of pulse immunosuppressive therapy, increasing the dose of prednisone to 30 mg daily and introducing azathioprine (100 mg daily). Before starting this therapeutics, there was a clinical discussion with the CLP team about the risks of recurrent mental and behavioral disorders and the need for prophylactic treatment. Rheumatologists initially suggested both preventive hospitalization in the Psychiatric Ward of the General Hospital of Unicamp and questioned the need of prescribing psychotropic drugs, considering the patient's positive psychiatric history.

As the patient had not presented any abnormalities at the mental examination, there was a consensus that she should undergo the treatment proposed by the rheumatologists' team, with hospitalization at the ward of that medical specialty, without introducing psychotropic drugs, but maintaining evaluations by the CLP team. On the third day of hospitalization, however, the patient developed emotional lability, accused the care team and got aggressive with a nursing assistant. She made several disconnected notes, no longer recognized the physicians who hospitalized her and presented dysphoria and hypersexuality. The presentation evolved to temporary remission only after the administration of benzodiazepines. Up to this point, a precise psychiatric diagnosis had not been reached. After being discharged from the hospital, the patient continued with psychiatric follow-up consultations at the outpatient clinic, when she presented psychiatric symptoms again, which became manic, requiring the introduction of a mood stabilizer (lithium carbonate, 1 tablet of 300 mg every 12 hours) and a antipsychotic (risperidone, 1 tablet, 2 mg per day, at night) with no new mental and behavioral events after that.

Discussion

At this clinical report, the doubts raised by the possible recurrence of the psychiatric disorders with the new pulse of prednisone were discussed by the psychiatry and rheumatology teams, prior to the patient's hospitalization. The clinical treatment program was carried out according to the previously agreed plan.

The psychiatric diagnosis of organic mental disorder due to the administration of corticosteroids was better established during the follow-up period and was classified as an organic manic mood disorder, which justified the therapy that improved the patient's mental conditions.

In addition to illustrating the presentation of a rare clinical condition, the described psychiatric report exemplifies the benefits of joint and planned actions between psychiatry and other medical specialties. Considering the patient's psychiatric history, there was an agreement that psychiatric comorbidities shall be treated as long as they occur, aiming to optimize the overall treatment, which should be established according to the current psychopathological manifestations. Thus, a psychiatric hospitalization and the continued use of medications not specifically fitted to the symptoms manifested, which became clearer during the follow-up period, were avoided.

Acknowledgements

We would like to acknowledge and thank the whole rheumatology team involved in the care delivered to the patient. Because of their concern for the patient's early mental and behavioral manifestations, the rheumatology team facilitated the implementation of a regimen, aiming to avoid complications from major neuropsychiatric symptoms and the consequences thereof.

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Publication Dates

• Publication in this collection
  12 Mar 2010
• Date of issue
  2009

History

• Accepted
  25 Mar 2009
• Received
  26 Feb 2009