534000 research-article2014
APY0010.1177/1039856214534000Australasian PsychiatrySadhu et al.
Australasian
Psychiatry
Psychosis
Psychosis in paratyphoid fever – a case report from Australia
Australasian Psychiatry 2014, Vol 22(3) 242–244 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214534000 apy.sagepub.com
Raja Sadhu Department of Psychiatry, Werribee Mercy Hospital, Werribee, VIC, Australia Amin Pourzehad Gilani Department of Medicine, Werribee Mercy Hospital, Werribee, VIC, Australia Marc Lanteri Department of Medicine, Werribee Mercy Hospital, Werribee, VIC, Australia Manoj Kumar Department of Psychiatry, Werribee Mercy Hospital, Werribee, VIC, Australia
Abstract Objective: Neuropsychiatric presentation in paratyphoid fever is not a well-known entity. In countries such as Australia, where the prevalence of enteric fever is one of the lowest, this presentation seems to be unlikely. Method: We present a case that demonstrates the importance of considering this possibility in Australian context in returned travellers. Results: A young male, who recently returned to Australia from his home country in South East Asia, presented with abnormal behaviour in the context of febrile illness. His behaviour was characterised by grandiosity, aggression, hallucinatory behaviour and paranoia, along with disturbed biological functions. Detailed inpatient assessment revealed him to be suffering from Salmonella Paratyphi A infection and psychotic illness because of his general medical condition. Although his fever and inflammatory markers responded to antibiotics, antipsychotics were required for treatment of his mental health problems. Conclusion: This case demonstrates that paratyphoid fever, which is considered to be a less common variant of enteric fever, can present with neuropsychiatric manifestations. Keywords: paratyphoid fever, organic psychosis, traveller
R
ecently there has been a several fold increase in the incidence of paratyphoid fever in several regions of Asia that had been earlier considered to be endemic for enteric fever.1,2 Paratyphoid fever, a less common variant of enteric fever,2 has been considered to have a less severe course2 than typhoid fever. However, recent reports are demanding a change in this understanding.2 Conceptually the presence of Vi capsular antigen in Salmonella enterica serotype Typhi makes it more virulent,2 as compared to Salmonella enterica serotype Paratyphi A, which lacks it.2 However, for some unknown reasons Salmonella Paratyphi A infections have recently presented with equal severity2 and factors such as consumption of street food, migratory status and flooding have been considered contributory.1,3 The lack of suitable available preventive vaccine1,2 for Salmonella Paratyphi A infections and also the emergence of its multiple antibiotic resistant strains1,2 make our situation difficult. Neuropsychiatric manifestations in typhoid fever are well described and can indicate poor prognosis and outcome.4,5 According to the literature, the neuropsychiatric manifestations can range from psychiatric
242
presentations such as psychosis, delirium, mania, depression, personality change to various neurologic presentations such as seizure, meningism, hemiplegia, parkinsonian syndrome, neuropathy, motor neuron disorder and other focal neurodeficits. Although the deficits usually reverse quickly on recovery, occasionally there can be residual deficits.6,7 According to some authors, the risk of mortality increases in enteric fever complicated by central nervous system involvement.4 There has been a tendency for patients in developing countries to present more with neuropsychiatric manifestations as compared to those in developed countries, although the recent increase in travel and migration can change that balance.8 In many of these situations, the role of typhoid fever was not obvious or was missed.6,8 On reviewing the literature available on Pubmed, we found that most of the reports on neuropsychiatric Corresponding author: Dr Raja Sadhu, Werribee Mercy Psychiatry Unit, Werribee Mercy Hospital, 300 Princes Highway, Werribee, VIC 3030, Australia. Email: [email protected]
Sadhu et al.
manifestations of enteric fever dealt with patients suffering from typhoid fever.4–7 There is a scarcity of literature describing neuropsychiatric manifestations in Salmonella Paratyphi infections. We could not find any previous report of neuropsychiatric presentation of paratyphoid fever from Australia. The incidence rates of typhoid and paratyphoid fevers in Australia are among the lowest in the world.2 However, travel to developing countries is a risk factor for developing these illnesses in Australia, and when patients present with neuropsychiatric complications their diagnosis and management can be challenging. Here we report a case of paratyphoid fever in a young man who had presented with psychiatric symptoms.
Case report A 32-year-old male of South-east Asian origin presented to the emergency department with abnormal behaviour in the context of two weeks of febrile illness. He lived with his family in Australia, had completed a degree, and worked full-time as a store manager. He admitted intermittent recreational use of marijuana, heroin and cocaine 10 years ago, in the absence of any recent use. He denied having any past or family history of mental health problems. He travelled to his home country in Asia for one month to get married, and after coming back to Australia developed fever (without chill and rigor), myalgia, lethargy and complained of intermittent headache and neck pain. He attended his general practitioner after five days, who prescribed a course of oral penicillin. He took that for more than a week without much benefit and then started behaving abnormally. The patient’s family members found him agitated, swearing and elevated in his mood, which was unusual for him. He developed grandiose delusions of being very powerful; he felt his body was so strong that he could ‘go through concrete walls’. He believed he was a powerful movie character (Transformer), and felt he was ‘in heaven’. He complained of sore throat, swollen tongue and continuous occipital headache, and was observed to have poor sleep and appetite. Because of these abnormal behaviours, the development of verbal and physical aggression, and refusal to seek help, he was restrained and brought to hospital with the help of police officials. On examination he was tachycardic (128/min), tachypnoeic (24/min, with 99% oxygen saturation), febrile (39.5°C) and hypertensive (150/90 mm Hg); although he was awake and alert, his Glasgow Coma Scale (GCS) score was 13 (eye opening response – 4, verbal response – 4, motor response – 5). His pupils were equal and reactive to light, there was no meningism, neck stiffness or focal neurological deficit; cardiovascular, respiratory, gastrointestinal, lymphoreticular and genitourinary system examinations were all normal. Investigations revealed hyponatremia (131 mmol/L) and raised
C-reactive protein (64 mg/L); blood culture grew a gram negative bacillus, identified as Salmonella Paratyphi A. Computerised tomography (CT) brain, cerebrospinal fluid (CSF) analysis, screening for other infections (including HIV), and other routine investigations were within normal limits. He was treated with intravenous (IV) ceftriaxone and Acyclovir; after 48 hours the fever subsided, biochemical abnormalities and inflammatory markers resolved, but behavioural symptoms continued. Initially restraint was necessary to prevent self-discharge. He removed his IV cannula, appeared suspicious, and was intermittently aggressive towards staff (threatening to kill his doctor and the doctor’s child). He exhibited inappropriate behaviour (pointing towards walls), and reported auditory and visual hallucinations. Later he was found to be over-religious, over-familiar with staff (expressing inappropriate love for his doctor), and overtalkative with labile affect. He slept and ate poorly during this period. After five days, following discussion with an infectious disease specialist, antibiotics were switched to oral Azithromycin for a further five-day course. Psychiatric evaluation revealed increased psychomotor activity, jocularity, increased rate and productivity of speech, lability of affect, increased flow of thought and grandiose delusions. His attention was aroused and sustained, he was found to be oriented to time place and person, he could remember all that had happened earlier without any prompt and gave a vivid description of all his experiences. His bedside immediate, short- and longterm memory testing revealed no abnormality and his abstraction ability (similarity and proverb testing) appeared intact, although he showed impaired judgement and poor insight. He was diagnosed with organic psychosis, recommended under the mental health act and started on oral Olanzapine (15 mg/day); over the next two days his mental state and insight improved. He was discharged and sent home as a voluntary patient on crisis assessment and treatment team (CATT) follow up on antibiotics and antipsychotics with instructions to continue Olanzapine for six months. After a few home visits by the CATT, he was referred to the community continuing care team for follow up. The patient visited the continuing care team a few times over a couple of weeks; he opted to stop Olanzapine because it caused him sedation, in spite of the advice to the contrary. Hence the antipsychotic was tapered and stopped successfully over a period of four weeks under supervision of the psychiatry consultant.
Discussion With the increased incidence of paratyphoid fever in South East Asia1,2 and increased incidence of enteric fever in travellers visiting these places,2 it is important that we become aware of the possibility of such infections in returned travellers coming back to Australia. Use of vaccine effective for Salmonella Typhi but not for Salmonella Paratyphi A has been postulated by some
243
Australasian Psychiatry 22(3)
authors as contributory to this situation.1,2 Besides this, the antibiotic resistance pattern of this strain as compared to Salmonella Typhi is also of great concern.1,2 In cases of typhoid fever, the interval between the onset of fever and the onset of psychiatric symptoms can range from 7 to 18 days.9 In this case of paratyphoid fever the interval was approximately 13 days. We initially considered a possibility of delirium in this case; however, although the GCS score was low, he was never found to be disoriented. In fact, the low GCS score apparently was because of uncooperativeness resulting from psychotic symptoms. Inpatient investigations excluded encephalitis and established the diagnosis of paratyphoid fever. The possibility of antibiotic-induced psychosis was excluded because of lack of improvement in psychiatric symptoms in spite of change in antibiotics. The presentation in this patient resembled mania with psychotic features. Although symptoms of delusion, auditory and visual hallucinations are common in psychiatric presentations of typhoid (46%, 56% and 18% of patients, respectively), elation is less common7 (6%). There are only a few reports of typhoid fever presenting with hypomania8 or bipolarity10 and virtually no specific report of this kind of presentation in paratyphoid fever. The psychiatric symptoms in our patient did not resolve with appropriate antibiotic therapy, but responded quickly to antipsychotic treatment. It is not clear why some patients with enteric fever develop neuropsychiatric manifestations and others do not. Mechanisms postulated include pyrexia, endotoxins, metabolic deficiency, protein calorie deficiency, vitamin deficiency, immune mediation, biochemical disturbances, anaemia, associated pneumonia, susceptible personality and multifactorial causation.6,7,11 Because of the role of the inflammatory process behind these
244
presentations some authors have suggested the use of steroids in these patients.5 In conclusion, paratyphoid infection, a less common variant of enteric fever, which is gaining importance because of its severity, antibiotic resistance and lack of appropriate vaccine, can present in Australia with neuropsychiatric manifestations in the returned traveller. Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Fangtham M and Wilde H. Emergence of Salmonella paratyphi A as a major cause of enteric fever: need for early detection, preventive measures, and effective vaccines. J Travel Med 2008; 15: 344–350. 2. Pegues DA and Miller SI. Salmonellosis. In: Longo DL, Fauci SA, Kasper DL, et al. (eds) Harrisons principles of internal medicine. 18th ed. New York: McGraw Hill Medical, 2012, pp.1274–1280 3. Karkey A, Thompson CN, Tran Vu Thieu N, et al. Differential epidemiology of Salmonella Typhi and Paratyphi A in Kathmandu, Nepal: a matched case control investigation in a highly endemic enteric fever setting. PLoS Negl Trop Dis 2013; 7: e2391. 4. Aghanwaa HS and Morakinyob O. Correlates of psychiatric morbidity in typhoid fever in a Nigerian general hospital setting. Gen Hosp Psychiatr 2001; 23: 158–162. 5. Ollé-Goig JE and Ruiz L. Typhoid fever in rural Haiti. Bull Pan Am Health Organ 1993; 27: 382–388. 6. Osuntokun BO, Bademosi O, Ogunremi K, et al. Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol 1972; 27: 7–13. 7. Hafeiz HB. Psychiatric manifestations of enteric fever. Acta Psychiatr Scand 1987; 75: 69–73. 8. Edsall G. Psychiatric symptoms in typhoid fever. Br Med J 1973; 2: 714–715. 9. Lakhotia M, Gehlot RS, Jain P, et al. Neurological manifestations of enteric fever. J Indian Acad Clin Med 2003; 4: 196–199. 10. Santangelo CG, Goldstein D and Green S. A case of bipolar disorder and typhoid fever. Int J Psychiatr Med 2004; 34: 267–269. 11. Ali G, Rashid S, Kamli MA, et al. Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Trop Med Int Health 1977; 2: 314–318.
APY0010.1177/1039856214534000Australasian PsychiatrySadhu et al.
Australasian
Psychiatry
Psychosis
Psychosis in paratyphoid fever – a case report from Australia
Australasian Psychiatry 2014, Vol 22(3) 242–244 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214534000 apy.sagepub.com
Raja Sadhu Department of Psychiatry, Werribee Mercy Hospital, Werribee, VIC, Australia Amin Pourzehad Gilani Department of Medicine, Werribee Mercy Hospital, Werribee, VIC, Australia Marc Lanteri Department of Medicine, Werribee Mercy Hospital, Werribee, VIC, Australia Manoj Kumar Department of Psychiatry, Werribee Mercy Hospital, Werribee, VIC, Australia
Abstract Objective: Neuropsychiatric presentation in paratyphoid fever is not a well-known entity. In countries such as Australia, where the prevalence of enteric fever is one of the lowest, this presentation seems to be unlikely. Method: We present a case that demonstrates the importance of considering this possibility in Australian context in returned travellers. Results: A young male, who recently returned to Australia from his home country in South East Asia, presented with abnormal behaviour in the context of febrile illness. His behaviour was characterised by grandiosity, aggression, hallucinatory behaviour and paranoia, along with disturbed biological functions. Detailed inpatient assessment revealed him to be suffering from Salmonella Paratyphi A infection and psychotic illness because of his general medical condition. Although his fever and inflammatory markers responded to antibiotics, antipsychotics were required for treatment of his mental health problems. Conclusion: This case demonstrates that paratyphoid fever, which is considered to be a less common variant of enteric fever, can present with neuropsychiatric manifestations. Keywords: paratyphoid fever, organic psychosis, traveller
R
ecently there has been a several fold increase in the incidence of paratyphoid fever in several regions of Asia that had been earlier considered to be endemic for enteric fever.1,2 Paratyphoid fever, a less common variant of enteric fever,2 has been considered to have a less severe course2 than typhoid fever. However, recent reports are demanding a change in this understanding.2 Conceptually the presence of Vi capsular antigen in Salmonella enterica serotype Typhi makes it more virulent,2 as compared to Salmonella enterica serotype Paratyphi A, which lacks it.2 However, for some unknown reasons Salmonella Paratyphi A infections have recently presented with equal severity2 and factors such as consumption of street food, migratory status and flooding have been considered contributory.1,3 The lack of suitable available preventive vaccine1,2 for Salmonella Paratyphi A infections and also the emergence of its multiple antibiotic resistant strains1,2 make our situation difficult. Neuropsychiatric manifestations in typhoid fever are well described and can indicate poor prognosis and outcome.4,5 According to the literature, the neuropsychiatric manifestations can range from psychiatric
242
presentations such as psychosis, delirium, mania, depression, personality change to various neurologic presentations such as seizure, meningism, hemiplegia, parkinsonian syndrome, neuropathy, motor neuron disorder and other focal neurodeficits. Although the deficits usually reverse quickly on recovery, occasionally there can be residual deficits.6,7 According to some authors, the risk of mortality increases in enteric fever complicated by central nervous system involvement.4 There has been a tendency for patients in developing countries to present more with neuropsychiatric manifestations as compared to those in developed countries, although the recent increase in travel and migration can change that balance.8 In many of these situations, the role of typhoid fever was not obvious or was missed.6,8 On reviewing the literature available on Pubmed, we found that most of the reports on neuropsychiatric Corresponding author: Dr Raja Sadhu, Werribee Mercy Psychiatry Unit, Werribee Mercy Hospital, 300 Princes Highway, Werribee, VIC 3030, Australia. Email: [email protected]
Sadhu et al.
manifestations of enteric fever dealt with patients suffering from typhoid fever.4–7 There is a scarcity of literature describing neuropsychiatric manifestations in Salmonella Paratyphi infections. We could not find any previous report of neuropsychiatric presentation of paratyphoid fever from Australia. The incidence rates of typhoid and paratyphoid fevers in Australia are among the lowest in the world.2 However, travel to developing countries is a risk factor for developing these illnesses in Australia, and when patients present with neuropsychiatric complications their diagnosis and management can be challenging. Here we report a case of paratyphoid fever in a young man who had presented with psychiatric symptoms.
Case report A 32-year-old male of South-east Asian origin presented to the emergency department with abnormal behaviour in the context of two weeks of febrile illness. He lived with his family in Australia, had completed a degree, and worked full-time as a store manager. He admitted intermittent recreational use of marijuana, heroin and cocaine 10 years ago, in the absence of any recent use. He denied having any past or family history of mental health problems. He travelled to his home country in Asia for one month to get married, and after coming back to Australia developed fever (without chill and rigor), myalgia, lethargy and complained of intermittent headache and neck pain. He attended his general practitioner after five days, who prescribed a course of oral penicillin. He took that for more than a week without much benefit and then started behaving abnormally. The patient’s family members found him agitated, swearing and elevated in his mood, which was unusual for him. He developed grandiose delusions of being very powerful; he felt his body was so strong that he could ‘go through concrete walls’. He believed he was a powerful movie character (Transformer), and felt he was ‘in heaven’. He complained of sore throat, swollen tongue and continuous occipital headache, and was observed to have poor sleep and appetite. Because of these abnormal behaviours, the development of verbal and physical aggression, and refusal to seek help, he was restrained and brought to hospital with the help of police officials. On examination he was tachycardic (128/min), tachypnoeic (24/min, with 99% oxygen saturation), febrile (39.5°C) and hypertensive (150/90 mm Hg); although he was awake and alert, his Glasgow Coma Scale (GCS) score was 13 (eye opening response – 4, verbal response – 4, motor response – 5). His pupils were equal and reactive to light, there was no meningism, neck stiffness or focal neurological deficit; cardiovascular, respiratory, gastrointestinal, lymphoreticular and genitourinary system examinations were all normal. Investigations revealed hyponatremia (131 mmol/L) and raised
C-reactive protein (64 mg/L); blood culture grew a gram negative bacillus, identified as Salmonella Paratyphi A. Computerised tomography (CT) brain, cerebrospinal fluid (CSF) analysis, screening for other infections (including HIV), and other routine investigations were within normal limits. He was treated with intravenous (IV) ceftriaxone and Acyclovir; after 48 hours the fever subsided, biochemical abnormalities and inflammatory markers resolved, but behavioural symptoms continued. Initially restraint was necessary to prevent self-discharge. He removed his IV cannula, appeared suspicious, and was intermittently aggressive towards staff (threatening to kill his doctor and the doctor’s child). He exhibited inappropriate behaviour (pointing towards walls), and reported auditory and visual hallucinations. Later he was found to be over-religious, over-familiar with staff (expressing inappropriate love for his doctor), and overtalkative with labile affect. He slept and ate poorly during this period. After five days, following discussion with an infectious disease specialist, antibiotics were switched to oral Azithromycin for a further five-day course. Psychiatric evaluation revealed increased psychomotor activity, jocularity, increased rate and productivity of speech, lability of affect, increased flow of thought and grandiose delusions. His attention was aroused and sustained, he was found to be oriented to time place and person, he could remember all that had happened earlier without any prompt and gave a vivid description of all his experiences. His bedside immediate, short- and longterm memory testing revealed no abnormality and his abstraction ability (similarity and proverb testing) appeared intact, although he showed impaired judgement and poor insight. He was diagnosed with organic psychosis, recommended under the mental health act and started on oral Olanzapine (15 mg/day); over the next two days his mental state and insight improved. He was discharged and sent home as a voluntary patient on crisis assessment and treatment team (CATT) follow up on antibiotics and antipsychotics with instructions to continue Olanzapine for six months. After a few home visits by the CATT, he was referred to the community continuing care team for follow up. The patient visited the continuing care team a few times over a couple of weeks; he opted to stop Olanzapine because it caused him sedation, in spite of the advice to the contrary. Hence the antipsychotic was tapered and stopped successfully over a period of four weeks under supervision of the psychiatry consultant.
Discussion With the increased incidence of paratyphoid fever in South East Asia1,2 and increased incidence of enteric fever in travellers visiting these places,2 it is important that we become aware of the possibility of such infections in returned travellers coming back to Australia. Use of vaccine effective for Salmonella Typhi but not for Salmonella Paratyphi A has been postulated by some
243
Australasian Psychiatry 22(3)
authors as contributory to this situation.1,2 Besides this, the antibiotic resistance pattern of this strain as compared to Salmonella Typhi is also of great concern.1,2 In cases of typhoid fever, the interval between the onset of fever and the onset of psychiatric symptoms can range from 7 to 18 days.9 In this case of paratyphoid fever the interval was approximately 13 days. We initially considered a possibility of delirium in this case; however, although the GCS score was low, he was never found to be disoriented. In fact, the low GCS score apparently was because of uncooperativeness resulting from psychotic symptoms. Inpatient investigations excluded encephalitis and established the diagnosis of paratyphoid fever. The possibility of antibiotic-induced psychosis was excluded because of lack of improvement in psychiatric symptoms in spite of change in antibiotics. The presentation in this patient resembled mania with psychotic features. Although symptoms of delusion, auditory and visual hallucinations are common in psychiatric presentations of typhoid (46%, 56% and 18% of patients, respectively), elation is less common7 (6%). There are only a few reports of typhoid fever presenting with hypomania8 or bipolarity10 and virtually no specific report of this kind of presentation in paratyphoid fever. The psychiatric symptoms in our patient did not resolve with appropriate antibiotic therapy, but responded quickly to antipsychotic treatment. It is not clear why some patients with enteric fever develop neuropsychiatric manifestations and others do not. Mechanisms postulated include pyrexia, endotoxins, metabolic deficiency, protein calorie deficiency, vitamin deficiency, immune mediation, biochemical disturbances, anaemia, associated pneumonia, susceptible personality and multifactorial causation.6,7,11 Because of the role of the inflammatory process behind these
244
presentations some authors have suggested the use of steroids in these patients.5 In conclusion, paratyphoid infection, a less common variant of enteric fever, which is gaining importance because of its severity, antibiotic resistance and lack of appropriate vaccine, can present in Australia with neuropsychiatric manifestations in the returned traveller. Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Fangtham M and Wilde H. Emergence of Salmonella paratyphi A as a major cause of enteric fever: need for early detection, preventive measures, and effective vaccines. J Travel Med 2008; 15: 344–350. 2. Pegues DA and Miller SI. Salmonellosis. In: Longo DL, Fauci SA, Kasper DL, et al. (eds) Harrisons principles of internal medicine. 18th ed. New York: McGraw Hill Medical, 2012, pp.1274–1280 3. Karkey A, Thompson CN, Tran Vu Thieu N, et al. Differential epidemiology of Salmonella Typhi and Paratyphi A in Kathmandu, Nepal: a matched case control investigation in a highly endemic enteric fever setting. PLoS Negl Trop Dis 2013; 7: e2391. 4. Aghanwaa HS and Morakinyob O. Correlates of psychiatric morbidity in typhoid fever in a Nigerian general hospital setting. Gen Hosp Psychiatr 2001; 23: 158–162. 5. Ollé-Goig JE and Ruiz L. Typhoid fever in rural Haiti. Bull Pan Am Health Organ 1993; 27: 382–388. 6. Osuntokun BO, Bademosi O, Ogunremi K, et al. Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol 1972; 27: 7–13. 7. Hafeiz HB. Psychiatric manifestations of enteric fever. Acta Psychiatr Scand 1987; 75: 69–73. 8. Edsall G. Psychiatric symptoms in typhoid fever. Br Med J 1973; 2: 714–715. 9. Lakhotia M, Gehlot RS, Jain P, et al. Neurological manifestations of enteric fever. J Indian Acad Clin Med 2003; 4: 196–199. 10. Santangelo CG, Goldstein D and Green S. A case of bipolar disorder and typhoid fever. Int J Psychiatr Med 2004; 34: 267–269. 11. Ali G, Rashid S, Kamli MA, et al. Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Trop Med Int Health 1977; 2: 314–318.
