Attending physician’s mental notes: interim follow-up information through 72 hours (continued)

Again, this fluctuating and acute-onset presentation is not suggestive of this patient’s usual psychopathology

It does appear to be getting worse in regard to the new-onset psychosis, but the confusion and waxing/waning of consciousness are still present, indicating delirium has returned

Was refusing medicine again at home; she could now be in sedative withdrawal

The antibiotic ciprofloxacin has known CYP450 3A4 interactions; could she have a delirium now secondary to a drug toxicity?

Question

What would you tell the emergency room team now?

The clinical picture is still textbook delirium and that likely her urosepsis was incompletely treated and infection may have returned

She may have a new medical issue causing this and IV or IM lorazepam (Ativan) should be given as she is refusing oral clonazepam tablets. This should treat or rule out a sedative withdrawal etiology

Sometimes delirious symptoms may continue for a few days after medical treatment is given and these remaining psychiatric phenomenon should be treated with low-dose antipsychotics for a few more days

A drug interaction check shows no problems among her current medications (including ciprofloxacin), but there should be a re-evaluation for new medical insults causing an escalation in her delirium

If there is continued debate between providers over this presentation being a functional psychosis versus an organic, medically induced delirium, what would you suggest?

A CT scan was performed acutely at admission the first time. It showed no acute hemorrhage or tumor, but cannot initially rule out ischemic infarctions or microembolic events. Her VNS pacemaker can be turned off, and an MRI of the brain conducted if the MRI can be set up safely to avoid heating the VNS pacemaker wires

A lumbar puncture can be performed to rule out infection or inflammatory processes in the CNS that cannot be detected by CT scan or MRI

An EEG can be performed, and if diffuse slowing is noted, then this is reasonably indicative of delirium and not psychiatric disorder

Case outcome: interim follow-up information through 92 hours

An EEG is performed and shows bifrontal diffuse slowing with occasional beta intrusions, suggesting ongoing delirium

IV ciprofloxacin is restarted to make sure urosepsis is cleared

No other clear medical cause is determined as yet

Patient is placed on 0.5–1.5 mg/d of the typical antipsychotic haloperidol (Haldol) that can be given via multiple routes of administration, which is advantageous if she refuses oral tablets again

Case debrief

This patient has a clear history of chronic MDD and GAD, which finally became responsive to PDP, medication polypharmacy, and VNS adjunctive therapy

A near-remission status was maintained for two to three years

She became acutely confused with altered consciousness, and then frankly paranoid, in a fluctuating course over one to three days, which is uncharacteristic

• – Given her history of no previous similar exacerbations of depression or any substance misuse

• – Or of other psychiatric disorders associated with psychosis, e.g., schizophrenia, bipolar disorder, or MDD

• – The clinical picture most accurately reflects an acute medical delirium

This was adequately treated at first by detecting the underlying medical cause, second with behavioral interventions, and third with pharmacologic intervention

A noninvasive EEG was performed, helping clear up the debate over the dilemma of delirium versus a new functional psychotic event

The delirium symptoms gradually cleared over the next few days with continued antibiotics, haloperidol, and supportive care