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Conversion disorder mimicking serotonin syndrome in an adolescent taking sertraline.

We present the case of a 15-year-old-boy on sertraline (Zoloft) who presented to the Emergency Department with palpitations, tremor, and weakness after starting erythromycin. Upon admission to the hospital, he developed syncopal-like episodes of unresponsiveness associated with body-wide jerking and stiffening as well as tachycardia and hypertension. He was initially believed to have serotonin syndrome and was transferred to a pediatric Intensive Care Unit where the diagnosis of conversion disorder was made. We discuss the salient features of serotonin syndrome and conversion disorder and emphasize the importance of making either diagnosis.

Conversion disorder: "an adverse reaction" to watch out for.

A subject was enrolled in a multicenter, double-blinded clinical trial of ofloxacin-containing multidrug therapy for leprosy by the World Health Organization in 1992 and she developed multiple physical symptoms a few hours after taking the regimen. Physical examination and laboratory work-ups could not support a medical diagnosis and she was eventually dropped from the study. Decoding revealed that she belonged in the control group given the World Health Organization/multiple drug therapy-multibacillary regimen. In the course of treatment, she was diagnosed with conversion disorder and was subsequently treated with an antipsychotic.

Camptocormia induced by atypical antipsychotics and resolved by electroconvulsive therapy.

We present a depressive patient who developed mild parkinsonian signs and camptocormia after the introduction of olanzapine. She had been treated before with other antipsychotic drugs. When camptocormia was diagnosed, olanzapine was withdrawn and levodopa was introduced. Depressive symptoms got worse and electroconvulsive therapy was tried. When the treatment was completed, her depression substantially improved and her posture became completely upright.

Unexpected neurologic deficit following spinal anesthesia.

BACKGROUND AND OBJECTIVES: A case of unexpected neurologic deficit of the left lower extremity following a successful spinal block is reported. METHODS: A spinal block was performed in a 45-year-old woman with a 25-gauge Whitaker needle at the L3-L4 interspace. After establishing flow of clear cerebrospinal fluid, 1.6 mL of 0.75% bupivacaine was injected into the subarachnoid space. The patient had a good motor and sensory block (level T4), and she underwent uneventful extracorporeal shock wave lithotripsy of a right kidney stone. After satisfactory recovery in the postanesthesia care unit, she was transferred to the ambulatory surgical center for further recovery and discharge home. RESULTS: About 11 hours after administration of the spinal anesthetic and recovery from the spinal block, the patient complained of not being able to move her left leg. Neurologic examination revealed motor loss and hyperesthesia to touch, vibration, pressure, and temperature from her groin to toes in the left leg only. The remainder of the neurologic examination was normal. A nuclear magnetic resonance scan of the spine revealed no abnormality. Neurologic and psychiatric consultations were sought, and the patient was diagnosed to have a conversion disorder. She responded to psychological intervention and returned to her previous state of health in 2 weeks. CONCLUSIONS: Neurologic deficit following spinal or epidural block should be investigated completely and appropriate consultations sought. Psychiatric disorder may be a rare cause of neurologic deficit after successful regional anesthesia and should be made part of a complete workup.

Induction of pseudoseizures with intravenous saline placebo.

For a 2-year period, all patients admitted to the inpatient adult EEG videotelemetry unit of the University of Miami School of Medicine underwent attempted event induction with intravenous normal saline placebo. Of 175 patients monitored during that period, 101 underwent attempted placebo saline induction, whereas 58 patients were either in the pediatric age group, were undergoing a repeat hospitalization (i.e., depth electrode monitoring), or refused induction. The final diagnosis in each patient was established after review of the history; physical, interictal, and ictal EEG findings; brain imaging studies; interictal and postictal brain single photon emission computed tomography (SPECT) and serum prolactin levels; psychiatric and psychological evaluations; and detailed neuropsychological testing. Final diagnoses were separated into epilepsy alone, pseudoseizures, epilepsy and pseudoseizures, and other (neither epilepsy nor pseudoseizures). No patient with an eventual diagnosis of epilepsy alone was inducible. Forty-one patients with a diagnosis of epilepsy were not inducible. Of 32 patients with an eventual diagnosis of pseudoseizures, 29 were inducible. One of these 29 was also diagnosed with epilepsy. Three patients with an eventual diagnosis of pseudoseizures were not inducible; 90.6% of patients with an eventual diagnosis of pseudoseizures were inducible, i.e., had events identical to those reported by history, after injection of saline placebo. Placebo saline injection is a safe and effective means of distinguishing epilepsy from pseudoseizures.

The prolonged benzodiazepine withdrawal syndrome: anxiety or hysteria?

In an attempt to establish whether prolonged withdrawal symptoms after stopping intake of benzodiazepines is caused by return of anxiety, hysteria, abnormal illness behaviour or the dependence process itself producing perhaps a prolonged neurotransmitter imbalance, a group of such patients suffering prolonged withdrawal symptoms (PWS) was compared on a range of psychophysiological measures with matched groups of anxious and conversion hysteria patients and normal controls. It was found that the psychophysiological markers of anxiety were not marked in the PWS group; nor were the averaged evoked response abnormalities found to be associated with cases of hysterical conversion in evidence. The PWS group were hard to distinguish from normal controls on the basis of psychophysiological measures and thus it was felt to be unlikely to be an affective disturbance. It was concluded that PWS is likely to be a genuine iatrogenic condition, a complication of long-term benzodiazepine treatment.

Prolonged LSD flashbacks as conversion reactions.

This paper presents a case study of the background and treatment of a patient with prolonged LSD flashbacks. The hypothesis that flashbacks can be psychologically determined symptoms is supported by the dynamics of the case and the course of treatment. A second focus is a partial explanation for the often made observation that obessive-compulsive personalities are at increased risk for LSD flashbacks.

[Iatrogenic myoclonic encephalopathies caused by bismuth salts]. / Encéphalopathies myocloniques iatrogènes aux sels de bismuth

Since the beginning of 1974, we have studied 17 cases of iatrogenic encephalopathy due to the ingestion of bismuth taken for the treatment of chronic digestive disorders. More than 100 similar cases have been reported in France within the same period. The clinical picture is remarkably consistent: there is a relatively long prodromal phase with difficulties in gait and writing, followed by a phase characterised by four signs, namely a severe confusional syndrome, myoclonus, astasia-abasia and sisorders of language. In our cases, after withdrawal of bismuth, recovery invariably began within 2 to 3 weeks but fatal cases have been described. All our patients had taken, for periods of between 3 weeks and 20 years, bismuth subnitrate. The levels of bismuth in the blood and urine in these patients were between 10 and 100 times as great as those in patients who had taken the same treatment without ill effect. The exact mechanism by which bismuth causes this complication, described only recently, is totally unknown.