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Psychiatric Aspects of Non-HIV Infectious Diseases. Robert K. Schneider, MD Michael J. Robinson, MD James L. Levenson, MD. Why Now?. Global Society Increased Travel Increased Immigration/Emigration Broader Medical Management HIV Malignancies Transplantation People living longer.

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Psychiatric aspects of non hiv infectious diseases l.jpg

Psychiatric Aspects ofNon-HIV Infectious Diseases

Robert K. Schneider, MD

Michael J. Robinson, MD

James L. Levenson, MD

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Why Now?

  • Global Society

    • Increased Travel

    • Increased Immigration/Emigration

  • Broader Medical Management

    • HIV

    • Malignancies

    • Transplantation

  • People living longer

Infectious disease syndromes chapter 52 robert k schneider james l levenson l.jpg
Infectious Disease SyndromesChapter 52Robert K. SchneiderJames L. Levenson

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Risk Groups

Immune Status


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Risk Groups

  • Immune Status

    • Elderly

    • Chronic Disease

      • HIV

      • Malignancy

      • Transplant

      • Diseases where immunosuppressants are used

        • (ie SLE, Psoriasis, IPF)

    • Substance Abuse

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Risk Groups

  • Demographics

    • Children

    • Recreational Activities

    • Occupation

    • Region of origin or residence

    • Travel

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  • Consider infectious causes when patient is in the risk group

    • Immune Status

    • Demographics

  • Activate an appropriate differential diagnosis

  • Know the best tests to evaluate these patients

  • Know the best treatments for these conditions

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Case One

Postpartum Woman with Psychosis

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Postpartum Woman with Psychosis

  • 34 yo woman 4 weeks postpartum

  • 3 week history of paranoid ideation and auditory hallucinations

  • Other points on history?

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Postpartum Woman with Psychosis

  • Recently emigrated from Mexico

  • The family reports seizure disorder since age 3

  • Several family members have seizures

  • Family reports no substance abuse

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What’s the differential diagnosis?

  • Postpartum psychosis

  • Ictal or interictal psychosis

  • Substance Abuse

  • Malignancy

  • Infectious causes

    • Brain Abscess

    • Toxoplasmosis

    • Neurocysticerosis

    • Tuberculosis

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Postpartum Woman from Mexico

  • EEG: “normal”

  • Urine Drug Screen: Negative

    (collateral family hx supports this)

  • CXR: normal

  • CBC: 7,000: 60 neut; 5 eos; 30 lymph; 5 mono

  • Hct: 40%

  • Biochemical Profile: WNL

  • HIV: negative

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Postpartum Woman from Mexico

  • Head CT with and without contrast: multiple cystic and calcified lesions

  • CSF:

    • 24 WBC all lymphs

    • Protein and Glucose: wnl

    • Stains: negative

    • Cultures: pending

  • Serology:

    • Pending

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Differential Diagnosis:Toxoplasmosis

  • Exceedingly common in general population

  • Disease occurs only in

    immunocompromized host

  • Most common treatable cerebral lesion in HIV

  • CT: ring enhancing lesions

  • CSF: pleocytosis

  • Serology: antibody positive 67%

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Differential Diagnosis:Tuberculosis

  • 15% extrapulomanry

  • Most CNS TB is parameningeal

    • Cerebral TB is very rare

  • CT scan: negative or meningeal granulomas

  • CSF: almost always reactive

    • Depressed glucose

    • Increased WBC

    • Markedly elevated protein

    • Stains positive 25%/Cultures positive 75%

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Differential Diagnosis:Brain Abscess

  • Patient usually with evidence of systemic infection

  • History of IVDA, Valvular heart disease or recent neurosurgery

  • CSF: virtually always positive, particularly on stains showing organisms

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  • The “Pork Tapeworm”

  • Caused by the larval form of Taenia solium

  • Most widely disseminated neuroparasitosis

  • CNS is the most frequently affected organ (92%)

  • Most common cause of seizures in endemic areas

  • Endemic in Latin America, sub-Saharan Africa, India and China

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  • Inactive disease

  • Active disease

    • Parenchymal

    • Ventricular

    • Subarachnoid

    • Spinal and ocular

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  • CT scan is the primary means of diagnosis

  • Most commonly reveals inactive disease

    • <1 cm calcifications

    • Hydrocephalus is evident secondary to obstructive intraventricular disease

  • Active Disease

    • Ring enhancing cystic lesions

    • Pathognomonic scolex is sometimes seen in the cyst

    • Meningeal disease is hard to detect on CT

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How good is serology in NCC?

  • CDC immunoblot assay

  • Acknowledged as immunodiagnositic by:

    • World Health Organization

    • Pan American Health Organization

  • 100% specific

  • Sensitivity varies:

    • Multiple lesions: 90%

    • Single enhancing parenchymal cysts: <50%

    • Clinically defined patients with calcified cysts: 70%

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What are the Psychiatric Aspects of NCC?

  • Depression: >50% in outpatient setting

  • Psychosis: 14% in outpatient, probably higher at presentation (inpatient)

  • Delirium often present at presentation

  • Cognitive decline and symptoms of hydrocephalus

  • Headache is common but nonspecific

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What’s the best treatment?

  • If inactive disease, no treatment except for the seizure disorder.

  • If active disease, corticosteroids and praziquantel is the main stay.

  • However, praziquantel is toxic and recent RCT suggest no benefit over symptomatic treatment.

  • In hydrcephalus (usually inactive, chronic NCC) surgically shunting is indicated.

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What areas of the US is NCC rising?

  • Prevalence in US is increasing, especially in areas with high immigrant populations

    • (eg Texas, California)

  • Most cases occur among Latin American immigrants

  • Local transmission is probably higher than expected

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Does NCC occur in travelers?

  • Yes

  • Can occur with only brief contact

  • Risk increases the longer the contact

    Cysticercosis surveillance: Locally acquired and travel-rated infections and detection of intestinal tapeworm carriers in Los Angeles Count. Sorvillo FJ, Waterman SH, Richards FO, Schantz PM. Am J Trop Med Hyg. 1992;47(3),365-371.

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Are you safe if you don’t eat pork?

  • No

  • Most transmission occurs from eating food that is fertilized with pork or human waste

  • Also carriers that are food handlers can transmit T. solium

  • NCC occurred in an Orthodox Jewish community in New York City. Infection was secondary to food handlers who were carriers of T solium

    Neurocysticerosis in an Ortodox Jewish Community in New York city. Schantz PM, Moore AC, Munoz JL, et al. NEJM 1992;327:692-5

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Case Two

The Pediatric Patient

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The Case

  • LR is a 5 year old girl who presents with the following complaints from her parents:

  • HPI:

    • “she has recently started to obsess about everything”

    • “she is constantly counting to four”

    • “everything has to be in its certain place or she gets really upset”

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The Case

  • “she repeatedly blinks” and “jerks her head the the side”

  • “she later started to do things with her voice”

  • Other associated behavior complaints

  • Recent PMHx:

    • sick with a fever on and off for the last few months

    • CXR - normal

    • No other investigations have been performed

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    The Case

    • Past Psych Hx:

      • None; No emotional, behavioral, or school problems noted

    • Past Medical Hx:

      • early childhood recurrent otitis media, not requiring myringotomy tubes or prophylactic antibiotics

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    The Case

    • Family hx:

      • first of 2 children; healthy younger brother

      • maternal hx of depression responsive to antidepressant medications

      • maternal grandmother with a hx of trichotillomania

      • paternal hx of vocal tics as a child

      • No OCD, No Sydenham’s chorea, No Rheumatic fever

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    Differential Diagnosis

    • OCD

    • ADHD

    • Separation Anxiety

    • PANDAS

    • Sydenham’s Chorea

    • Transient Tic Disorder

    • Tourette’s Disorder / Chronic Motor or Vocal Tic Disorder

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    Initial Work-Up?

    • Throat Culture Positive for GABHS

    • Anything else?

      • MRI?

      • D8/17?

      • Anti-GABHS antibody titres? Which ones?

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    • PANDAS = ?

    • Inclusionary Criteria:

      • Presence of OCD and/or tic disorder

      • Pediatric onset

      • Episodic course of symptom severity

      • Association with GABHS infection

      • Association with neurological abnormalities

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    • Proposed Pathogenesis:

      • Pathogen + Susceptible Host  Immune Response  Sydenham’s Chorea or PANDAS

    Pandas41 l.jpg

    • Association with GABHS?

      • Positive throat culture

        • Is a positive throat culture enough to demonstrate recent GABHS infection?

      • Elevated ASO and/or AntiDNase-B titres

        • Are elevated titres enough to demonstrate recent GABHS infection?

      • Can a child have a relapse of symptoms without evidence for a recent GABHS infection?

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    • Any other investigations?

      • Is an MRI warranted?

      • What is the significance of B-lymphocyte antigen D8/17? Should we test for it?

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    PANDAS - Treatment Options

    • Antibiotics?

      • Acute treatment and/or prophylaxis?

    • Plasma exchange/Plasmaphoresis

    • Intravenous immunoglobulin

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    Case Three

    Tick-bitten Hikers

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    35 year-old woman, hiked Appalachian Trail•One week: flu-like symptoms, large rash on groin, facial palsy, Lyme serology negative • Two months: headache, stiff neck, arm numb and burning• One year: depression, fatigue, forgetful

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    36-year-old man, hiked Glacier National Park• One week: flu-like symptoms, parethesias in hands and feet• Two months: headache, stiff neck, fatigue, Lyme serology positive• One year: depression, fatigue, diffuse myalgia

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    Lyme Disease

    • Caused by spirochete, Borrelia burgdorfei

    • Transmitted by deer ticks (<5% risk)

    • Over 10,000 cases/year reported in U.S.

    • Over 90% from 8 states (CT, RI, NY, NJ, PA, MD, WI, MN)

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    Disease Onset (One week)

    Erythema migrans, >90%

    Central clearing, <40%

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    Acute Disseminated Disease (First month)

    • Fatigue, 54%

    • Myalgia/arthralgia, 44%

    • Headache, 42%

    • Fever/chills, 39%

    • Stiff neck, 35%

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    Subacute Disease (Months)

    • Arthritis, oligoarticular, most often knee, 60%

    • Secondary skin lesions, 50%

    • Neurological, 15%

      – Cranial neuropathy, most often VII

      – Meningitis

      – Painful radiculopathy

      • Carditis (conduction disturbance), 5-10%

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    Chronic Disease (Years)

    • Dermatitis

    • Arthritis

    • Neurological

      – Mild sensory radiculopathy

      – Cognitive dysfunction

      – Depression

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    Chronic Neuroborreliosis – Diagnostic Tests

    • CSF abnormal (>50%):  protein, Ab positive

    • MRI abnormal (25%): White matter lesions

    • EEG normal

    • Neuropsych testing abnormal

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    Lyme disease is a clinical diagnosisSerology can support but not make diagnosis

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    • Two step

    • Initial: ELISA (or IPA)

    • If positive: Western blot

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    Serology Limitations

    • False negative in early infection

    • False negative after early antibiotics

    • False positive in other infections, autoimmune diseases

    • True positive uncorrelated with time or activity

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    • Acute disease:

      • oral doxycycline or amoxicillin, 2-4 weeks

    • Neuroborreliosis:

      • IV ceftriaxone, 2-4 weeks

    • Complete recovery is the rule

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    • Prophylaxis not recommended after tick bite

    • Cover up and DEET

    • Vaccine effective

      • 50-70% first year

      • 75-90% second year

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    35-year-old woman, hiked Appalachian Trail• One week: flu-like symptoms, large rash on groin, facial palsy• Two months: headache, stiff neck, arm numb and burning• One year: depression, fatigue, forgetful

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    36-year-old man, hiked Glacier National Park• One week: flu-like symptoms, parethesias in hands and feet• Two months: headache, stiff neck, fatigue, Lyme serology positive• One year: depression, fatigue, diffuse myalgia

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    Differential Diagnosis

    • Fibromyalgia

    • Chronic fatigue syndrome

    • Other infections

    • Somatoform disorders

    • Depression

    • Autoimmune diseases

    • Multiple sclerosis

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    Consequences of Overdiagnosis & Overtreatment

    • Somatization

    • Invalidism

    • Antibiotic side effects

      “Lyme colitis” (Clostridia enteropathy)