Dear Sir: Kumar and colleagues Reference Kumar, Sivaraman, Chinnamani, Rathore, Thangaraju and Pandey(1) recently reported a case of viral encephalopathy, which presented a schizophrenia-like psychotic disorder. This clinical fact has been scarcely described. Psychotic symptoms could be frequent in the acute encephalitis population Reference Ramirez-Bermudez, Soto-Hernandez, Lopez-Gomez, Mendoza-Silva, Colin-Piana and Campillo-Serrano(2), often accompanied by neurological symptoms as headache, fever, seizures, as in the case by Kumar et al., or even meningeal signs. Brain infections are a frequent cause of delirium Reference Ramirez-Bermudez, Lopez-Gomez, Sosa, Aceves, Nader-Kawachi and Nicolini(3), and delusional-hallucinatory phenomena might be linked to dopaminergic hyperactivity in this population Reference Ramirez-Bermudez, Ruiz-Chow, Pérez-Neri, Soto-Hernandez, Flores-Hernández, Nente and Rios(4). However, a few cases may present with minimal or none neurological signs and symptoms and may present, from a neuropsychiatric phenomenological approach, an acute psychotic episode. We present three cases attended at the National Institute of Neurology and Neurosurgery of Mexico.
Case 1. A 29-year-old previously healthy male, without family history of mental disorders, began his illness 45 days before admission with fatigue, insomnia, irritability, mannerisms, auditory hallucinations, somatic and thought control delusions, physical aggressiveness and psychomotor agitation. Physical and neurological exams were normal. Lack of cooperation impeded cognitive exploration, but orientation and immediate attention were preserved. The psychiatric symptoms described earlier were confirmed by clinical interview. Psychiatric admission diagnosis was schizophreniform disorder. electroencephalogram (EEG) was delayed because of uncooperativeness. At his fourth day of hospitalisation, while treated with risperidone, he developed a single seizure episode, cardio-respiratory arrest and died. On autopsy, macroscopic and microscopic pathology cerebral studies showed results compatible with viral meningoencephalitis, diffuse cerebral oedema and anoxia.
Case 2. An 18-year-old woman, without previous personal or family psychiatry history, began her episode 12 days before admission with visual and auditory hallucinations, mystic delusions, insomnia, laughing without external conditioning, disorganised behaviour and psychomotor agitation. Physical and neurological exams were normal. Detailed cognitive exploration was not possible because of uncooperativeness, but the level of alertness, orientation and immediate attention was preserved. magnetic resonance imaging (MRI) was normal. EEG showed epileptiform elements. Cerebrospinal fluid (CSF) analysis showed inflammatory reaction with increased proteins and cells, predominantly lymphocytes. Initial diagnosis was psychotic episode because of viral encephalitis. After 9 days, she was discharged with complete recovery while being treated with haloperidol. After 1 year, she developed a second psychotic episode characterised by dromomany, hyporexia, insomnia, agitation and catatonic signs. Electroconvulsive therapy (ECT) offered her a complete remission. After 2 years of follow-up, she was asymptomatic.
Case 3. A 19-year-old male, without family or personal history of mental disorders, was admitted after 22 days with a disorder characterised by irritability, auditory hallucinations and megalomaniac, control and nihilistic delusions. Physical and neurological exams were normal. Detailed cognitive exploration was not possible because of lack of cooperation, but the level of alertness, orientation and immediate attention was preserved. MRI was normal. EEG showed acute paroxysmal waves. Lumbar puncture was performed to rule out an acute brain infection, and CSF analysis showed increased cells and proteins (predominantly lymphocytes). A psychotic disorder because of viral encephalitis was considered. He was discharged after 45 days with complete remission, while treated with perfenazine. After 15 months, he had a new episode with megalomaniac and persecution delusions and visual hallucinations. He was treated with ECT obtaining remission in positive signs. A third episode, with similar characteristics developed 2 years later; he was treated successfully as outpatient with antipsychotic medication (perfenazine). Since then, he has been asymptomatic for a 31/2 year period.
The three cases were diagnosed as having a psychotic disorder. Current taxonomic systems (DSM-IV) allow the diagnosis of psychotic disorder occurring because of medical condition (5), in this case acute encephalitis probably of viral etiology. The criteria for differential diagnosis of patients with delirium, but also first episode psychosis, should consider this condition. In our cases, MRI was normal, but systematic EEG is useful, as most patients with acute encephalitis will have abnormal basal rhythm or paroxysmal waves. CSF study is necessary for diagnosis in these patients. Given the existence of predominant psychiatric presentations of acute encephalitis, how often should lumbar puncture be indicated in first onset psychotic disorders? The precise indications for lumbar puncture in psychiatric patients are a topic underestimated in neurology, psychiatry and neuropsychiatry textbooks. Patients with acute encephalitis and psychiatric presentations require a different setting for their management as compared with primary psychiatric patients, as well as specific treatment; this is highlighted by the fact that one patient in our case series had a fatal outcome.
Relapsing psychotic disorder in two of our three patients resembles a previously reported case with prolonged psychotic symptoms, accompanied by aggressiveness and hypersexuality, observed in a female adolescent 3 months after the acute phase of herpes encephalitis Reference Yamamoto and Abe(6), although brain pathology, EEG and MRI studies in our cases, did not show evidence of herpetic etiology. Notwithstanding, neuropsychiatric sequels as psychosis (6%) and aggressiveness (9%) in patients with non-herpetic encephalitis (at 1 year follow-up) have also been reported Reference Ramirez-Bermudez, Soto-Hernandez, Lopez-Gomez, Mendoza-Silva, Colin-Piana and Campillo-Serrano(2).
