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.