Cases That Test Your Skills

A curious case of depression

Current Psychiatry. 2011 October;10(10):53-58

References

1. Stern TA, Rosenbaum JF, Fava M, et al. eds. Massachusetts General Hospital comprehensive clinical psychiatry. Philadelphia, PA: Mosby; 2008;257-277.

2. Andrade L, Caraveo-Anduaga JJ, Berglund P, et al. The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. Int J Methods Psychiatr Res. 2003;12(1):3-21.

3. Merikangas KR, Low NC. The epidemiology of mood disorders. Curr Psychiatry Rep. 2004;6:411-421.

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8. Hildebrand J, Aoun M. Chronic meningitis: still a diagnostic challenge. J Neurol. 2003;250(6):653-660.

9. Bacon RM, Kugeler KJ, Mead PS. Centers for Disease Control and Prevention (CDC). Surveillance for Lyme disease—United States 1992-2006. MMWR Surveill Summ. 2008;57(10):1-9.

10. Hájek T, Pasková B, Janovská D, et al. Higher prevalence of antibodies to Borrelia burgdorferi in psychiatric patients than in healthy subjects. Am J Psychiatry. 2002;159:297-301.

11. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134.

12. Krause PJ, Telford SR 3rd, Spielman A, et al. Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. JAMA. 1996;275(21):1657-1660.

13. Hildenbrand P, Craven DE, Jones R, et al. Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis. AJNR Am J Neuroradiol. 2009;30:1079-1087.

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Clinical Point

Clinical features of Lyme disease stages frequently overlap and some patients in later stages do not have prior signs or symptoms

The clinical features of each stage frequently overlap and some patients in a later stage of Lyme disease do not have prior signs or symptoms of the disease. Because it is a multisystem disease, Lyme disease can attack the CNS in the form of neuroborreliosis, a clinical diagnosis, without involving other systems, and its neuropsychiatric manifestations can resemble neurosyphilis because both organisms are spirochetes.^11,13,14 CNS disorders have been found in up to 40% of Lyme disease cases.¹¹ In neuroborreliosis, cognitive problems usually predominate; however, neuroborreliosis can mimic multiple brain diseases presenting with various neurologic and psychiatric symptoms (Table 4)^14,15 and can present at any time after the tick bite. Furthermore neuroborreliosis is difficult to diagnose because symptoms may remain dormant and emerge after several years.^11,13,14Borrelia burgdorferi is challenging to isolate and grow in the lab, and enzyme-linked immunosorbent assay (ELISA) testing for antibodies is highly specific but not very sensitive,¹⁶ frequently giving false negative results. Western blot confirms the diagnosis.

Table 4

Late-stage neuropsychiatric symptoms of Lyme disease

Cognitive problems, memory problems, forgetfulness, slowing of thought processing, dysfunction in visuospatial orientation, dyslexia
Depression
Mood swings
Psychosis
Violent behavior/irritability
OCD
Anxiety
Panic attacks
Sleep disorders
Seizures
ADHD-like symptoms
Autism-like behavior
Chronic fatigue syndrome
Fibromyalgia
ADHD: attention-deficit/hyperactivity disorder; OCD: obsessive-compulsive disorder Source: References 14,15

Mr. Z’s presentation also reflects co-infection with babesiosis. Babesia is malaria-like protozoa diagnosed by blood smear that can cause a fatal illness in immuno-compromised patients. The clinical picture varies from mild symptoms such as night sweats, chills, arthralgias, and anorexia with thrombocytopenia to severe and potentially fatal outcomes in immunocompromised patients, including DIC, acute renal failure, sepsis, congestive heart failure, and myocardial infarction.¹¹ Risk factors for the severest forms of babesiosis are age >50, co-infection with Lyme disease, and splenectomy,¹¹ all of which were present in Mr. Z. Co-infected patients experience fatigue, headache, anorexia, and emotional lability more frequently than those with Lyme disease alone.¹²

Treatment options

Clinical Point

Despite treatment, many Lyme disease patients have continued impairment, including pain, fatigue, and cognitive symptoms

Treatment of Lyme disease/neuroborreliosis is complex. The mainstay approach is antibiotics. Despite adequate treatment, many patients experience continued impairment, including chronic pain, fatigue, and cognitive and psychiatric symptoms.^11,14 There is some evidence Borrelia burgdorferi can persist and re-emerge after adequate treatment.^14,17 The National Institute of Health sponsored several clinical trials of prolonged antibiotic treatment for chronic Lyme disease. Some results suggested improvement in fatigue and cognitive function, although these results were not sustained.¹⁸

There is a strong link between mental illness and increased prevalence of positive Lyme disease antibodies.¹⁰ Several studies report increased risk of infection during psychological stress that may be related to an altered immune system response.¹⁹ Evidence suggests that Borrelia burgdorferi can alter immune system response, making T cells more reactive not only to Borrelia burgdorferi antigens but also to host antigens,²⁰ creating autoimmune inflammatory reactions that could explain chronic neuropsychiatric symptoms. It appears Lyme disease antigens can mimic certain autoantigens (for example, in the thyroid gland).²¹ Whether there is a role for autoimmune therapy in treating chronic symptoms needs to be investigated.

Clinical Point

Many Lyme disease patients report feeling stigmatized, making educating patients and family an important part of treatment

Once Lyme disease is diagnosed, educating patients and families becomes an important part of treatment because many patients report feeling stigmatized by the diagnosis. Referral to a Lyme disease support group may be beneficial. Patients with neuropsychiatric symptoms that persist after antibiotic treatment should be offered symptom-based treatment, including medications and therapy.

Related Resource

Centers for Disease Control and Prevention. Lyme disease: Resources for clinicians. www.cdc.gov/lyme/healthcare/clinicians.html.

Drug Brand Names

Divalproex sodium • Depakote
Levothyroxine • Levoxyl, Synthroid
Risperidone • Risperdal

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.