Clinical and neuropsychological characteristics of general paresis misdiagnosed as primary psychiatric disease.

BACKGROUND: Neurosyphilis is caused by the invasion of Treponema pallidum into the central nervous system. General paresis (GP) is a type of neurosyphilis. The main manifestation of general paresis is dementia; however, this is different from the other types of dementia, which can be cured by adequate doses of penicillin in the early stage. Neurosyphilis is the "great imitator" because it can mimic many types of medical disorders. In addition, the manifestations of neurosyphilis are not typical. Psychiatric disorders as a cause of general paresis have become more common due to the use of antibiotics. Patients with a psychiatric manifestation are often misdiagnosed. The purpose of this study was to explore the differences in the clinical and neuropsychological characteristics of general paresis between patients misdiagnosed as having a primary psychiatric disease and patients diagnosed correctly upon seeing a doctor. The results may assist clinicians in the early identification of neurosyphilis with a mental disorder. METHOD: The demographic and clinical manifestations, laboratory tests, and neuroimaging and neuropsychological characteristics were analysed in 55 general paresis patients with psychiatric disorders, including 29 patients misdiagnosed as primary psychiatric disease and 26 patients diagnosed as having general paresis after being seen once by a doctor. RESULT: All of the patients had positive assay results for cerebral spinal fluid (CSF) Treponema pallidum hemagglutination (TPHA). Only 43.3 % of misdiagnosed patients and 30.8 % of general paresis patients had positive results for the CSF rapid plasma reagin (RPR) test; 96.4 % patients had abnormal neuroimaging. Mood disturbances were the most common psychiatric disorder in the general paresis patients, especially agitation, between the two groups (patients with general paresis who were misdiagnosed as having primary psychiatric disease and patients who had never been misdiagnosed) (p = 0.011). CONCLUSION: Our findings reinforce the importance of performing serologic testing for syphilis. This should be a part of the evaluation of patients with psychiatric disorders, especially patients with cognitive impairment. When the syphilis serology is positive, the patient should be examined thoroughly for neurosyphilis by lumbar puncture. Brain imaging could also aid the physician in discriminating these patients from those with a functional mental disorder.

Insight and attitudes towards medication among inpatients with chronic schizophrenia in the US and China.

BACKGROUND: The impact of culture on insight on illness and attitudes towards medication among patients with schizophrenia has not been well studied. We compared inpatients in the US and in China (a culture that numerous studies have shown heavily stigmatizes mental illness and psychosis), on measures of insight and acceptance of medication, controlling for overall severity of schizophrenia symptoms. METHODS: Clinical antipsychotic treatment for intervention effectiveness (CATIE) was a large study of pharmacotherapy of people with schizophrenia across the US. Insight was measured using the insight and treatment attitudes questionnaire (ITAQ) and attitudes towards medication by the drug attitude inventory (DAI) and symptoms of schizophrenia by the Positive and Negative Syndrome Scale (PANSS). These measures were applied to a sample of hospitalized patients diagnosed with schizophrenia at the Guangzhou Psychiatric hospital, the largest psychiatric hospital in Southern China. Mean ITAQ and DAI scores, net of total schizophrenia symptoms and other differences were compared at the time of admission using analysis of covariance. RESULTS: Both insight and favourable attitudes towards medication were significantly and substantially lower in the sample from Guangzhou on bivariate analysis even after adjusting for severity of overall schizophrenia symptoms on the PANSS. CONCLUSION: Inpatients in China had far lower scores on measures of insight and acceptance of their need for and benefits of medication, controlling for overall severity of schizophrenia symptoms, suggesting a significant impact of Chinese culture which is presumed to more heavily stigmatize mental illness and especially psychosis, although other explanations can not be ruled out.

Medial temporal lobe atrophy as a predictor of poor cognitive outcomes in general paresis.

BACKGROUND: The effect of penicillin therapy on clinical outcomes vary among patients with general paresis (GP). We sought to explore biomarkers that might serve as predictors of clinical outcomes in GP and identify patients requiring early intervention. METHODS: Thirty-five inpatients with GP were recruited. Each GP patient underwent comprehensive neuropsychological, neuroimaging and laboratory assessments before receiving penicillin therapy, and returned for follow-up evaluations after 6 months. The visual rating of medial temporal lobe atrophy (MTA) and the Fazekas scale was used to analyze the neuroimaging abnormalities. RESULTS: MTA scores were correlated with the pre-treatment cognitive scores and change in Mini Mental State Examination scores. GP patients with a Clinical Dementia Rating Scale (CDR) ≤1 or MTA scores ≤2 achieved significant improvement in neuropsychological test scores, as compared with patients with CDR >1 or MTA scores >2. Fazekas scale scores correlated with the pre-treatment attention scores. Significant improvements in cognitive test scores were observed in GP patients with normalization of serum rapid plasma regain (RPR) titers, but not those without normalization of RPR titers. CONCLUSIONS: Severe MTA may serve as a predictor of poor cognitive outcome and an indicator of severe cognitive impairment in GP patients. Thus, early interventions for improving cognitive function may be considered for GP patients with severe MTA. White matter hyperintensities may associated with attention impairment. Serum RPR titer may serve as a sensitive indicator of therapeutic effect in GP.