Understanding the Complexity of Early-Onset Dementia.

Dementia, particularly Alzheimer's disease, affects millions globally, with its prevalence increasing notably with age. Early-onset Alzheimer's disease, however, affects individuals under 65 years old. Unfortunately, diagnosing dementia in patients under 65 years old is quite challenging and is often delayed, missed, or wrong. Thus, we present the case of a 60-year-old female, with a medical history of hypothyroidism and presumed dementia on donepezil, who presented to the emergency department for agitation, dramatic change in personality and behavior, as well as cognitive decline that started in her late 50s. We discuss the importance of performing a thorough history and physical examination, as well as a comprehensive workup for patients who present with dramatic changes in behavior due to the wide range of potential diagnoses. While certain reversible causes, such as hypothyroidism, nutritional deficiencies, and polypharmacy, can be promptly identified and treated, chronic neurocognitive disorders such as Alzheimer's disease demand a timely evaluation for early multidisciplinary treatment to enhance patient outcomes.

Neuropsychiatric Manifestations of Arteriovenous Malformation: A Case of Acute Mania.

Current literature shows very few case reports about manic symptoms arising in patients with arteriovenous malformations and no other predisposing factors, where these cases presented with mania before the initiation of treatment. We report a rare case of a 46-year-old male patient, with a history of a left arteriovenous malformation (AVM) status post radiation treatment with associated seizures, who presented to the emergency department of a local hospital with acute mania and other behavioral changes. The patient had manic symptoms, including mood lability, impulsivity, insomnia, decreased appetite, jealous delusions, pressured speech, and suicidal ideations. The patient's escitalopram dose for depression was reduced from 20 mg to 10 mg, and valproate was started during admission. After a three-day hospital admission, his psychiatric symptoms gradually improved. He was subsequently discharged home with additional instructions to follow up with his neurologist. In this case report, we show that organic manic disorder should be considered in any manic patient who presents outside the usual age of onset for idiopathic manic-depressive disease, lacks a family or personal history of affective disturbance, or exhibits concomitant neurologic deficits. In addition, we emphasize that distinguishing between primary psychiatric conditions and those secondary to medical causes for patients who present with acute mania can significantly impact the care a patient receives and can make a difference in their psychiatric and medical prognosis.

Agranulocytosis Associated With Psychiatric Polypharmacy: Lessons Learned From a Clinical Case.

Psychiatric polypharmacy involves the use of two or more psychotropic medications to manage a mental and emotional condition. The prevalence of psychotropic polypharmacy has been increasing since the 1990s and has been attributed to the rise in multiple psychiatric conditions presenting in one patient. However, as the prevalence of polypharmacy increases to maximize therapeutic advantages, so does the adverse effect profile of those drugs used in combination, leading to very life-threatening effects such as agranulocytosis. Thus, we report a case of agranulocytosis secondary to polypharmacy in a patient with a history of multiple complex psychiatric conditions.  The patient is a 20-year-old female with a past medical history of major depressive disorder, borderline personality disorder, post-traumatic stress disorder, anxiety disorder, hypothyroidism, and ulcerative colitis. Her psychiatric conditions were managed with multiple medications including chlorpromazine, and clozapine was recently added a month prior to admission. Upon admission, the patient was hemodynamically stable and febrile, with complaints of generalized body aches and myalgia. Laboratory results showed profound leukopenia with a white blood cell count of 1.0x103/uL and a neutrophil number of 0.02x103/uL. The patient was admitted to the hospital for neutropenic sepsis and was aggressively treated with intravenous antibiotics. Her clozapine and chlorpromazine were discontinued. In this report, we discuss the association between chlorpromazine and clozapine use and agranulocytosis, emphasizing the importance of regular monitoring and heightened awareness for patients on these medications. This case also underscores the necessity for cautious polypharmacy medication management in individuals with complex psychiatric conditions, highlighting the potential life-threatening consequences of polypharmacy in this population.

Postoperative Altered Mental Status: A Case Report and Diagnostic Dilemma.

Postoperative altered mental status (AMS) is a prevalent and complex issue that poses a significant diagnostic challenge in the clinical setting. Clinical presentation consists of cognitive disturbances that can range from mild confusion to coma. Given the complexity and variability of AMS, each patient requires a careful and thorough evaluation to identify the underlying cause. Thus, we present a case of a 57-year-old male with confirmed left knee septic arthritis, whose admission was complicated by AMS following several incision and drainage procedures. We highlight the importance of considering a broad differential diagnosis when evaluating postoperative AMS, including electrolyte disturbances and systemic conditions. The case also discusses the importance of early recognition, interdisciplinary collaboration, and a comprehensive diagnostic strategy. By adopting a comprehensive and collaborative approach, healthcare providers can optimize patient outcomes and minimize complications in postoperative AMS cases. The patient's AMS was ultimately attributed to a combination of metabolic disturbances, drug-related factors, and systemic conditions. His severe psychiatric symptoms were successfully managed with targeted pharmacologic interventions.

Opioid Use in Pelvic Fractures: The Impact of Opioid Prescribing Laws in Pennsylvania.

Pennsylvania's Prescription Drug Monitoring Program (PDMP) was established in 2016, but its impact on opioid use for pelvic fractures is understudied. We compared opioid use in 277 pelvic fracture cases between two periods: 2015-2017 (T1) and 2018-2020 (T2). Outcomes included daily inpatient morphine milligram equivalents (MME), long-term opioid use (LOU) 60-90 days post-discharge, and intermediate-term opioid use (IOU) 30-60 days post-discharge. T1 and T2 had comparable baseline characteristics. T2 was associated with a decrease in average daily inpatient MME (58.6 vs 78.5, P = .02), particularly in younger patients. Regression analyses showed age and Injury Severity Score (ISS) were significant predictors for daily inpatient MME, while time period was not. Geriatric patients in T2 had significantly decreased IOU (30% vs 9%, P = .05). Pelvic fracture type and daily MME predicted IOU, while pelvic fracture type predicted LOU. This study suggests a modest impact of these laws, but further study is needed.

Exploring the Link Between Pancreatic Neuroendocrine Tumors and Depression: A Case Study.

This case probes the potential temporal relationship between pancreatic neuroendocrine tumor (PNET) and depression. This patient has chronic symptoms of depression with no formal diagnosis until within a year of doctors suspecting her diagnosis of pancreatic cancer. An excisional biopsy confirmed a grade 1 neuroendocrine tumor (NET) in the pancreas, and postoperative psychiatric consultation confirmed continued elevated depression. This report presents an illustrative example of the ongoing research questions surrounding the relationship between the timing of a depression diagnosis and a PNET diagnosis. The depression-before-diagnosis relationship in pancreatic cancer patients is an observation that warrants further studies as depression could be a valuable early warning sign of pancreatic cancer.

Insights Into the Association Between Myasthenia Gravis and Depression: A Clinical Case Study.

Myasthenia gravis (MG) is a serious and debilitating autoimmune disease characterized by muscle weakness, shortness of breath, and issues affecting the eyes, limbs, throat, and speech. Given the intense physical toll of the disease, it is unsurprising that higher rates of depression are observed among MG patients. We present a case involving a 30-year-old female patient who was admitted to the hospital for MG exacerbation and had a psychiatric consultation for worsening depression symptoms. The patient acknowledged symptoms of sad mood, crying spells, anhedonia, fatigue, insomnia, and inappropriate guilt. She admits to psychosocial stressors of her declining health, recent job loss, and low self-esteem due to weight gain. Past medical history includes a thymectomy and a total thyroidectomy that caused postsurgical-acquired hypothyroidism. She is currently on prednisone and pyridostigmine for her MG. The patient has many potential causes of her increased depressive symptoms, including her medications, psychosocial stressors, and her past medical history, in addition to her MG. However, the literature shows higher incidence rates of depression in MG patients compared to both healthy controls and controls with other comparable chronic conditions, as well as shows a positive association between increased depressive symptoms and MG severity. Thus, these findings prompt the consideration of possible physiological interplay between the two diseases and encourage further research into the association between MG and depression.