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A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis
General Hospital Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis Sevan Hotier, M.D. a,⁎, David Maltete, M.D., Ph.D. b, Bertrand Bourre, M.D. b, Xavier Jegouzo, M.D. a, Valérie Bourgeois, M.D. a, Olivier Guillin, M.D., Ph.D. a a b
Department of Psychiatry, Rouen University, France Departement of Neurology, Rouen University, France
a r t i c l e
i n f o
Article history: Received 23 September 2014 Revised 4 July 2015 Accepted 8 July 2015 Available online xxxx Keywords: Multiple Sclerosis Manic state Psychosis Orbitofrontal Corticosteroids
a b s t r a c t Several studies have reported a higher prevalence of unipolar depression and bipolar disorder among patients with multiple sclerosis (MS). However, only a few studies have reported manic episodes concomitant with new lesions enhanced by gadolinium on brain magnetic resonance imaging (MRI). Here we report the case of a 47-year-old woman suffering from MS admitted for a manic episode with psychotic features. Brain MRI revealed three new T2 lesions enhanced by gadolinium located in the corpus callosum and in ventromedial prefrontal regions. She rapidly recovered with intravenous methylprednisolone in combination with risperidone. In conclusion, in this patient, the fact that gadolinium-enhancing lesion coincided with new symptoms which responded quickly to corticosteroids suggests that the manic episode was an acute manifestation of MS. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The occurrence of psychopathological symptoms has been reported in multiple sclerosis (MS) as early as 1877 by Charcot. Major depression is reported as the most common psychiatric disturbance in MS, with a lifetime prevalence ranging from 6.94% to 70.1% [1]. Moreover, several epidemiological studies suggest that bipolar disorder (BD) is more frequent among MS patients. A recent case–control study reported a prevalence of 0.99% for type I BD and 7.5% for type II BD with an odds ratio of 32.2 in comparison with control subjects [2].
2. Case report Ms. G. is a 47-year-old single woman with relapsing and remitting MS, with an Expanded Disability Status Scale (EDSS) score of 7.0. Her medical history consists of a major depressive episode at the age of 32 treated by fluoxetine (20 mg per day), and a detrusor–external sphincter dyssynergia treated by tamsulosin (0.4 mg per day). Both treatments were taken for several years, without any recent dose modification. We did not find any personal or familial history of manic/hypomanic state or psychosis. Ms. G. has a part-time job of history teacher in a high school and is described as serious and upstanding by her family. ⁎ Corresponding author at: Department of Psychiatry, University of Rouen, 4 rue Paul Eluard, 76301, Sotteville-lès-Rouen, France. Tel.: +33 2 32 95 12 34; fax: +33 2 32 95 10 39. E-mail address: [email protected] (S. Hotier).
Her partner reported an acute onset of behavioral abnormalities beginning 10 days ago. She developed paranoid and suspicious thoughts associated with excessive irritability in the presence of marked mood lability, a decreased need for sleep, and thought and language disturbances (cluttering, flight of ideas). Neurological examination was unchanged compared to the last follow-up visit with her neurologist 6 weeks before. There were no signs of delirium or euphoria sclerotica syndrome. General examination did not reveal any significant abnormality, and routine blood tests and computed tomographic scan were unremarkable. An acute manic state with psychotic features was therefore diagnosed. After rapid fluoxetine withdrawal, an antipsychotic drug, risperidone, was introduced at the posology of 2 mg per day. Although aggressiveness and mood disorders were reduced, psychotic features as well as thought and language disturbances were not improved by risperidone. A magnetic resonance imaging (MRI) scan was performed, showing disseminated subcortical and periventricular white matter hyperintensities already present on the last follow-up MRI of May 2011. However, three new enhancing white matter lesions were observed: two in the subcortical right and left ventromedial prefrontal areas (Fig. 1) and one in the posterior right periventricular area, on the lateral part of the corpus callosum. In view of a manic state as an MS relapse, intravenous methylprednisolone (1 g per day, during 3 days) was started. The day following the end of the corticosteroid therapy, manic and delusional features were dramatically improved, allowing Ms. G. to be discharged from the hospital. One year after this episode, Ms. G. did not present any depressive or manic relapse. Cyclophosphamide has been introduced due to the progression of her motor disability.
http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Hotier S., et al, A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002
2
S. Hotier et al. / General Hospital Psychiatry xxx (2015) xxx–xxx
Fluoxetine, and antidepressants in general, can induce mood switches and could have generated our patient’s manic state. However, this possibility is unlikely because this drug was introduced several years before the manic episode, without any recent dose change. Brain MRI showed three new white matter lesions located in right corpus callosum and orbitofrontal regions. These last locations could have contributed to the mood switch of our patient, as orbitofrontal cortex is implicated in emotion regulation and social cognition [5]. Moreover, these three lesions had gadolinium enhancement, a feature that has rarely been described in published cases of neuropsychiatric relapses of MS [6–9]. In conclusion, the fact that gadolinium-enhancing lesions coincided with new symptoms which responded quickly to corticosteroids suggests that the manic episode of this patient was an acute manifestation of MS. Further controlled studies are needed to better characterize the optimal treatment of mood disorders affecting patients with MS. Fig. 1. Brain MRI of the present patient, T1+ gadolinium-infused sequences, showing gadolinium-enhanced white matter lesions of bilateral prefrontal ventromedial subcortical regions (arrowheads).
3. Discussion We present the case of a patient with MS who presented a manic state with psychotic features, revealing a type I BD due to another medical condition according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [3]. Brain MRI showed three new gadolinium-enhanced lesions. Finally, a rapid improvement of her psychiatric condition was observed after introducing risperidone and high-dose corticosteroids. The relationship between MS and the bipolar syndrome is well established. Indeed, MS is mentioned in DSM-5 as being among the best known medical causes of BD due to another medical condition [3]. Our patient has a severe form of MS, with an EDSS of 7.0. It could be argued that her symptoms were due to delirium or euphoria sclerotica syndrome. However, the absence of fluctuating course and attentional impairment argues against the first hypothesis. Euphoria sclerotica syndrome can be observed during the course of MS and is characterized by an elevated mood and an overoptimistic attitude despite the severity of the illness, but distinguishes from mania because of the absence of flight of ideas or hyperactivity [4].
Conflict of interest statement All authors declare that they have no conflict of interest for this report. References [1] Marrie RA, Reingold S, Cohen J, Stuve O, Trojano M, Sorensen PS, et al. The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review. Mult Scler 2015;21(3):305–17. [2] Carta MG, Moro MF, Lorefice L, Trincas G, Cocco E, Giudice ED, et al. The risk of bipolar disorders in multiple sclerosis. J Affect Disord 2014;155:255–60. [3] American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (DSM-5)5th ed. ; 2013[Arlington, VA]. [4] Paparrigopoulos T, Ferentinos P, Kouzoupis A, Koutsis G, Papadimitriou GN. The neuropsychiatry of multiple sclerosis focus on disorders of mood, affect and behaviour. Int Rev Psychiatry 2010;22(1):14–21. [5] Roy M, Shohamy D, Wagner TD. Ventromedial prefrontal–subcortical systems and the generation of affective meaning. Trends Cogn Sci 2012;16:147–56. [6] Blanc F, Berna F, Fleury M, Lita L, Ruppert E, Ferriby D, et al. Inaugural psychotic events in multiple sclerosis? Rev Neurol (Paris) 2010;166(1):39–48 [French]. [7] El Moutawakil B, Sibai M, Bourezqui M, Boulaajaj FZ, Rafai MA, Gam I, et al. Manic– depressive psychosis as prevalent manifestation of multiple sclerosis. Rev Neurol (Paris) 2008;164:472–6 [French]. [8] Modrego PJ, Ferrández J. Familial multiple sclerosis with repetitive relapses of manic psychosis in two patients (mother and daughter). Behav Neurol 2000;12:175–9. [9] Sidhom Y, Ben Djebara M, Hizem Y, Abdelkefi I, Kacem I, Gargouri A, Gouider R. Bipolar disorder and multiple sclerosis: a case series. Behav Neurol 2014;2014:536503.
Please cite this article as: Hotier S., et al, A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis Sevan Hotier, M.D. a,⁎, David Maltete, M.D., Ph.D. b, Bertrand Bourre, M.D. b, Xavier Jegouzo, M.D. a, Valérie Bourgeois, M.D. a, Olivier Guillin, M.D., Ph.D. a a b
Department of Psychiatry, Rouen University, France Departement of Neurology, Rouen University, France
a r t i c l e
i n f o
Article history: Received 23 September 2014 Revised 4 July 2015 Accepted 8 July 2015 Available online xxxx Keywords: Multiple Sclerosis Manic state Psychosis Orbitofrontal Corticosteroids
a b s t r a c t Several studies have reported a higher prevalence of unipolar depression and bipolar disorder among patients with multiple sclerosis (MS). However, only a few studies have reported manic episodes concomitant with new lesions enhanced by gadolinium on brain magnetic resonance imaging (MRI). Here we report the case of a 47-year-old woman suffering from MS admitted for a manic episode with psychotic features. Brain MRI revealed three new T2 lesions enhanced by gadolinium located in the corpus callosum and in ventromedial prefrontal regions. She rapidly recovered with intravenous methylprednisolone in combination with risperidone. In conclusion, in this patient, the fact that gadolinium-enhancing lesion coincided with new symptoms which responded quickly to corticosteroids suggests that the manic episode was an acute manifestation of MS. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The occurrence of psychopathological symptoms has been reported in multiple sclerosis (MS) as early as 1877 by Charcot. Major depression is reported as the most common psychiatric disturbance in MS, with a lifetime prevalence ranging from 6.94% to 70.1% [1]. Moreover, several epidemiological studies suggest that bipolar disorder (BD) is more frequent among MS patients. A recent case–control study reported a prevalence of 0.99% for type I BD and 7.5% for type II BD with an odds ratio of 32.2 in comparison with control subjects [2].
2. Case report Ms. G. is a 47-year-old single woman with relapsing and remitting MS, with an Expanded Disability Status Scale (EDSS) score of 7.0. Her medical history consists of a major depressive episode at the age of 32 treated by fluoxetine (20 mg per day), and a detrusor–external sphincter dyssynergia treated by tamsulosin (0.4 mg per day). Both treatments were taken for several years, without any recent dose modification. We did not find any personal or familial history of manic/hypomanic state or psychosis. Ms. G. has a part-time job of history teacher in a high school and is described as serious and upstanding by her family. ⁎ Corresponding author at: Department of Psychiatry, University of Rouen, 4 rue Paul Eluard, 76301, Sotteville-lès-Rouen, France. Tel.: +33 2 32 95 12 34; fax: +33 2 32 95 10 39. E-mail address: [email protected] (S. Hotier).
Her partner reported an acute onset of behavioral abnormalities beginning 10 days ago. She developed paranoid and suspicious thoughts associated with excessive irritability in the presence of marked mood lability, a decreased need for sleep, and thought and language disturbances (cluttering, flight of ideas). Neurological examination was unchanged compared to the last follow-up visit with her neurologist 6 weeks before. There were no signs of delirium or euphoria sclerotica syndrome. General examination did not reveal any significant abnormality, and routine blood tests and computed tomographic scan were unremarkable. An acute manic state with psychotic features was therefore diagnosed. After rapid fluoxetine withdrawal, an antipsychotic drug, risperidone, was introduced at the posology of 2 mg per day. Although aggressiveness and mood disorders were reduced, psychotic features as well as thought and language disturbances were not improved by risperidone. A magnetic resonance imaging (MRI) scan was performed, showing disseminated subcortical and periventricular white matter hyperintensities already present on the last follow-up MRI of May 2011. However, three new enhancing white matter lesions were observed: two in the subcortical right and left ventromedial prefrontal areas (Fig. 1) and one in the posterior right periventricular area, on the lateral part of the corpus callosum. In view of a manic state as an MS relapse, intravenous methylprednisolone (1 g per day, during 3 days) was started. The day following the end of the corticosteroid therapy, manic and delusional features were dramatically improved, allowing Ms. G. to be discharged from the hospital. One year after this episode, Ms. G. did not present any depressive or manic relapse. Cyclophosphamide has been introduced due to the progression of her motor disability.
http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Hotier S., et al, A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002
2
S. Hotier et al. / General Hospital Psychiatry xxx (2015) xxx–xxx
Fluoxetine, and antidepressants in general, can induce mood switches and could have generated our patient’s manic state. However, this possibility is unlikely because this drug was introduced several years before the manic episode, without any recent dose change. Brain MRI showed three new white matter lesions located in right corpus callosum and orbitofrontal regions. These last locations could have contributed to the mood switch of our patient, as orbitofrontal cortex is implicated in emotion regulation and social cognition [5]. Moreover, these three lesions had gadolinium enhancement, a feature that has rarely been described in published cases of neuropsychiatric relapses of MS [6–9]. In conclusion, the fact that gadolinium-enhancing lesions coincided with new symptoms which responded quickly to corticosteroids suggests that the manic episode of this patient was an acute manifestation of MS. Further controlled studies are needed to better characterize the optimal treatment of mood disorders affecting patients with MS. Fig. 1. Brain MRI of the present patient, T1+ gadolinium-infused sequences, showing gadolinium-enhanced white matter lesions of bilateral prefrontal ventromedial subcortical regions (arrowheads).
3. Discussion We present the case of a patient with MS who presented a manic state with psychotic features, revealing a type I BD due to another medical condition according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [3]. Brain MRI showed three new gadolinium-enhanced lesions. Finally, a rapid improvement of her psychiatric condition was observed after introducing risperidone and high-dose corticosteroids. The relationship between MS and the bipolar syndrome is well established. Indeed, MS is mentioned in DSM-5 as being among the best known medical causes of BD due to another medical condition [3]. Our patient has a severe form of MS, with an EDSS of 7.0. It could be argued that her symptoms were due to delirium or euphoria sclerotica syndrome. However, the absence of fluctuating course and attentional impairment argues against the first hypothesis. Euphoria sclerotica syndrome can be observed during the course of MS and is characterized by an elevated mood and an overoptimistic attitude despite the severity of the illness, but distinguishes from mania because of the absence of flight of ideas or hyperactivity [4].
Conflict of interest statement All authors declare that they have no conflict of interest for this report. References [1] Marrie RA, Reingold S, Cohen J, Stuve O, Trojano M, Sorensen PS, et al. The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review. Mult Scler 2015;21(3):305–17. [2] Carta MG, Moro MF, Lorefice L, Trincas G, Cocco E, Giudice ED, et al. The risk of bipolar disorders in multiple sclerosis. J Affect Disord 2014;155:255–60. [3] American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (DSM-5)5th ed. ; 2013[Arlington, VA]. [4] Paparrigopoulos T, Ferentinos P, Kouzoupis A, Koutsis G, Papadimitriou GN. The neuropsychiatry of multiple sclerosis focus on disorders of mood, affect and behaviour. Int Rev Psychiatry 2010;22(1):14–21. [5] Roy M, Shohamy D, Wagner TD. Ventromedial prefrontal–subcortical systems and the generation of affective meaning. Trends Cogn Sci 2012;16:147–56. [6] Blanc F, Berna F, Fleury M, Lita L, Ruppert E, Ferriby D, et al. Inaugural psychotic events in multiple sclerosis? Rev Neurol (Paris) 2010;166(1):39–48 [French]. [7] El Moutawakil B, Sibai M, Bourezqui M, Boulaajaj FZ, Rafai MA, Gam I, et al. Manic– depressive psychosis as prevalent manifestation of multiple sclerosis. Rev Neurol (Paris) 2008;164:472–6 [French]. [8] Modrego PJ, Ferrández J. Familial multiple sclerosis with repetitive relapses of manic psychosis in two patients (mother and daughter). Behav Neurol 2000;12:175–9. [9] Sidhom Y, Ben Djebara M, Hizem Y, Abdelkefi I, Kacem I, Gargouri A, Gouider R. Bipolar disorder and multiple sclerosis: a case series. Behav Neurol 2014;2014:536503.
Please cite this article as: Hotier S., et al, A manic episode with psychotic features improved by methylprednisolone in a patient with multiple sclerosis, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.07.002