Psychiatry and Clinical Neurosciences 2015; 69: 383–385
Glabellar ecchymosis and headache: Variations of pain-associated ecchymosis doi:10.1111/pcn.12266
W
E READ WITH great interest an article by Yulug et al.1 reporting a curious phenomenon: glabellar ecchymosis associated with trigemino-autonomic cephalgias in the left side. The phenomenon is explained by reflex neurogenic inflammation, demonstrated by Wesselmann and Lai in an animal model.2 They clarified skin extravasation over the abdomen, groin, lower back, thighs, perineal area and proximal tails in the rat with visceral experimental inflammation. We previously reported a girl with abdominal migraine having ecchymosis in bilateral legs and buttocks during spells of abdominal pain, which was the first clinical evidence of reflex neurogenic inflammation in visceral-pain-associated ecchymosis.3 The phenomenon may appear not only on the ipsilateral side of an insult but also on the contralateral side.2 With these previous reports, Yulug’s experience demonstrates the variations of pain-associated ecchymosis, in location and distribution. Physicians should keep these reports in mind when considering this curious phenomenon for better patient management.
REFERENCES 1. Yulug B, Hanoglu L, Schabitz WR. Headache and spontaneous glabellar ecchymosis: More than a self-injury behavior? Psychiatry Clin. Neurosci. 2014. doi: 10.1111/pcn.12220. 2. Wesselmann U, Lai J. Mechanisms of referred visceral pain: Uterine inflammation in the adult virgin rat results in neurogenic plasma extravasation in the skin. Pain 1997; 73: 309–317. 3. Kakisaka Y, Wakusawa K, Haginoya K, Uematsu M, Tsuchiya S. Abdominal migraine associated with ecchymosis of the legs and buttocks: Does the symptom imply an unknown mechanism of migraine? Tohoku J. Exp. Med. 2010; 221: 49–51.
Mayu Fujikawa, PhD1 and Naomi Hino-Fukuyo, MD2 Departments of 1Epileptology and 2Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan Email: [email protected] Received 2 November 2014; accepted 11 December 2014. Yosuke Kakisaka,
MD,1,2
Clinical diagnosis of rabies in a patient with schizophrenia doi:10.1111/pcn.12285
T
HE PREVALENCE OF rabies tends to be highest in developing countries. Because rabies may present with psychiatric symptoms, these patients could be initially misdiagnosed.1,2 There may be an even higher chance of an initial misdiagnosis when the patient has had a history of psychiatric disorders. A 59-year-old man was admitted by the emergency department with a headache and vomiting that had been ongoing for
Letters to the Editor 385
2 days. Physical examination revealed no additional abnormalities except for blood pressure (BP) of 170/95 mmHg. Blood tests determined the leukocyte count was 9.9 × 109 cells/L. A computed tomography scan of the brain was unremarkable. Oral diet was forbidden. The patient was hospitalized and supportive care was provided. The patient’s condition significantly worsened during the first night. Systemic examination revealed a pulse of 126 b.p.m. and a BP of 180/100 mmHg. Although optic fundi were normal, an abnormal mental state was discovered. The patient was agitated and became continuously aggressive and excited. He was started on a diazepam infusion and i.v. fluids. After being informed of the patient’s long history of schizophrenia by relatives, the physician first suspected a schizophrenic relapse presenting with acute psychosis. The next day, the patient was referred to the mental health center. On the second day, the patient’s condition deteriorated. He had a high fever of over 39.8°C and his leukocyte count suddenly increased to 28.8 × 109cells/L. However, there were no clear neurological symptoms. Diazepam infusion and i.v. fluids were continued. Antibiotic therapy was administered for suspected infection. Further inquiry was made into the patient’s disease history. By this point, the patient had been hospitalized 11 times for schizophrenia. Prior to this hospitalization, the patient’s relatives reflected that his status had been stable. The psychiatrist was also informed of the patient’s history of a dog bite 2 months prior, which had gone without a post-exposure prophylaxis. The classic characteristics of rabies, including aerophobia, hydrophobia, agitation and hallucination accompanied by high fever, became more apparent and progressed during the course of the second night. Rabies was then considered as a plausible diagnosis, and the patient was transferred to the infectious disease center. Both confirmation of a rabies diagnosis and death of the patient occurred during that night. To our knowledge, this is the first published report of a schizophrenic patient with rabies in China. A signed release has been obtained. Most psychiatrists will never encounter a case of rabies during their lifetime nor have training concerning rabies. The clinical features of rabies can be confusing due to a resemblance to psychiatric syndromes. Psychiatrists in particular should acknowledge and consider the possibility of being confronted with this problem. We also strongly suggest promoting awareness and knowledge of dog-bite prevention among schizophrenic patients.
REFERENCES 1. Schneider LS, Eth S. Observations on misdiagnosis of rabies. Psychosomatics 1985; 26: 338–340. 2. de Wet JS. Rabies presenting as an acute psychiatric emergency. S. Afr. Med. J. 1980; 58: 297–298.
Yuzhong Yan, MS,2† Lin Yao, MS,1 Yunduan Song, MS2 and Yi Shi, PhD2 1 Department of Psychiatry, Shanghai Pudong Nanhui Mental Health Center, and 2Department of Clinical Laboratory, Shanghai Pudong Hospital, Fudan University, Shanghai, China † Contributed equally. Email: [email protected] Received 12 December 2014; revised 23 January 2015; accepted 20 February 2015. Lihong Pan,
MB,1†
© 2014 The Authors Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology
Glabellar ecchymosis and headache: Variations of pain-associated ecchymosis doi:10.1111/pcn.12266
W
E READ WITH great interest an article by Yulug et al.1 reporting a curious phenomenon: glabellar ecchymosis associated with trigemino-autonomic cephalgias in the left side. The phenomenon is explained by reflex neurogenic inflammation, demonstrated by Wesselmann and Lai in an animal model.2 They clarified skin extravasation over the abdomen, groin, lower back, thighs, perineal area and proximal tails in the rat with visceral experimental inflammation. We previously reported a girl with abdominal migraine having ecchymosis in bilateral legs and buttocks during spells of abdominal pain, which was the first clinical evidence of reflex neurogenic inflammation in visceral-pain-associated ecchymosis.3 The phenomenon may appear not only on the ipsilateral side of an insult but also on the contralateral side.2 With these previous reports, Yulug’s experience demonstrates the variations of pain-associated ecchymosis, in location and distribution. Physicians should keep these reports in mind when considering this curious phenomenon for better patient management.
REFERENCES 1. Yulug B, Hanoglu L, Schabitz WR. Headache and spontaneous glabellar ecchymosis: More than a self-injury behavior? Psychiatry Clin. Neurosci. 2014. doi: 10.1111/pcn.12220. 2. Wesselmann U, Lai J. Mechanisms of referred visceral pain: Uterine inflammation in the adult virgin rat results in neurogenic plasma extravasation in the skin. Pain 1997; 73: 309–317. 3. Kakisaka Y, Wakusawa K, Haginoya K, Uematsu M, Tsuchiya S. Abdominal migraine associated with ecchymosis of the legs and buttocks: Does the symptom imply an unknown mechanism of migraine? Tohoku J. Exp. Med. 2010; 221: 49–51.
Mayu Fujikawa, PhD1 and Naomi Hino-Fukuyo, MD2 Departments of 1Epileptology and 2Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan Email: [email protected] Received 2 November 2014; accepted 11 December 2014. Yosuke Kakisaka,
MD,1,2
Clinical diagnosis of rabies in a patient with schizophrenia doi:10.1111/pcn.12285
T
HE PREVALENCE OF rabies tends to be highest in developing countries. Because rabies may present with psychiatric symptoms, these patients could be initially misdiagnosed.1,2 There may be an even higher chance of an initial misdiagnosis when the patient has had a history of psychiatric disorders. A 59-year-old man was admitted by the emergency department with a headache and vomiting that had been ongoing for
Letters to the Editor 385
2 days. Physical examination revealed no additional abnormalities except for blood pressure (BP) of 170/95 mmHg. Blood tests determined the leukocyte count was 9.9 × 109 cells/L. A computed tomography scan of the brain was unremarkable. Oral diet was forbidden. The patient was hospitalized and supportive care was provided. The patient’s condition significantly worsened during the first night. Systemic examination revealed a pulse of 126 b.p.m. and a BP of 180/100 mmHg. Although optic fundi were normal, an abnormal mental state was discovered. The patient was agitated and became continuously aggressive and excited. He was started on a diazepam infusion and i.v. fluids. After being informed of the patient’s long history of schizophrenia by relatives, the physician first suspected a schizophrenic relapse presenting with acute psychosis. The next day, the patient was referred to the mental health center. On the second day, the patient’s condition deteriorated. He had a high fever of over 39.8°C and his leukocyte count suddenly increased to 28.8 × 109cells/L. However, there were no clear neurological symptoms. Diazepam infusion and i.v. fluids were continued. Antibiotic therapy was administered for suspected infection. Further inquiry was made into the patient’s disease history. By this point, the patient had been hospitalized 11 times for schizophrenia. Prior to this hospitalization, the patient’s relatives reflected that his status had been stable. The psychiatrist was also informed of the patient’s history of a dog bite 2 months prior, which had gone without a post-exposure prophylaxis. The classic characteristics of rabies, including aerophobia, hydrophobia, agitation and hallucination accompanied by high fever, became more apparent and progressed during the course of the second night. Rabies was then considered as a plausible diagnosis, and the patient was transferred to the infectious disease center. Both confirmation of a rabies diagnosis and death of the patient occurred during that night. To our knowledge, this is the first published report of a schizophrenic patient with rabies in China. A signed release has been obtained. Most psychiatrists will never encounter a case of rabies during their lifetime nor have training concerning rabies. The clinical features of rabies can be confusing due to a resemblance to psychiatric syndromes. Psychiatrists in particular should acknowledge and consider the possibility of being confronted with this problem. We also strongly suggest promoting awareness and knowledge of dog-bite prevention among schizophrenic patients.
REFERENCES 1. Schneider LS, Eth S. Observations on misdiagnosis of rabies. Psychosomatics 1985; 26: 338–340. 2. de Wet JS. Rabies presenting as an acute psychiatric emergency. S. Afr. Med. J. 1980; 58: 297–298.
Yuzhong Yan, MS,2† Lin Yao, MS,1 Yunduan Song, MS2 and Yi Shi, PhD2 1 Department of Psychiatry, Shanghai Pudong Nanhui Mental Health Center, and 2Department of Clinical Laboratory, Shanghai Pudong Hospital, Fudan University, Shanghai, China † Contributed equally. Email: [email protected] Received 12 December 2014; revised 23 January 2015; accepted 20 February 2015. Lihong Pan,
MB,1†
© 2014 The Authors Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology
