Psychiatric presentations of non-HIV infectious diseases. Neurocysticercosis, Lyme disease, and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection

Pediatric neuropsychiatric disorders with motor and nonmotor phenomena

The concept of pediatric autoimmune neuropsychiatric disorders associated with group A beta-hemolytic streptococcus (PANDAS) has become seminal since first introduced more than two decades ago. At the time of this writing, most neurologists, pediatricians, psychiatrists, and general pediatricians will probably have heard of this association or treated an affected child with PANDAS. The concept of an acute-onset, and typically self-limited, postinfectious autoimmune neuropsychiatric disorder resembling PANDAS manifesting vocal and motor tics and obsessive-compulsive disorder has broadened to other putative microbes and related endogenous and exogenous disease triggers. These disorders with common features of hypometabolism in the medial temporal lobe and hippocampus in brain 18fluorodeoxyglucose positron emission tomography fused to magnetic resonance imaging (FDG PET-MRI), form a spectrum: with the neuropsychiatric disorder Tourette syndrome and PANDAS with its well-defined etiopathogenesis at one end, and pediatric abrupt-onset neuropsychiatric syndrome (PANS), alone or associated with specific bacterial and viral pathogens, at the other end. The designation of PANS in the absence of a specific trigger, as an exclusionary diagnosis, reflects the current problem in nosology.

Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist's Clinical Practice

There is increasing evidence and recognition that Lyme borreliosis (LB) causes mental symptoms. This article draws from databases, search engines and clinical experience to review current information on LB. LB causes immune and metabolic effects that result in a gradually developing spectrum of neuropsychiatric symptoms, usually presenting with significant comorbidity which may include developmental disorders, autism spectrum disorders, schizoaffective disorders, bipolar disorder, depression, anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, intrusive symptoms), eating disorders, decreased libido, sleep disorders, addiction, opioid addiction, cognitive impairments, dementia, seizure disorders, suicide, violence, anhedonia, depersonalization, dissociative episodes, derealization and other impairments. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient's complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression. Awareness of the association between LB and neuropsychiatric impairments and studies of their prevalence in neuropsychiatric conditions can improve understanding of the causes of mental illness and violence and result in more effective prevention, diagnosis and treatment.

Obsessive-compulsive symptoms in adults with Lyme disease

OBJECTIVE

This study examined the phenomenology and clinical characteristics of obsessive compulsive symptoms (OCS) in adults diagnosed with Lyme disease.

METHOD

Participants were 147 adults aged 18-82 years (M = 43.81, SD = 12.98) who reported having been diagnosed with Lyme disease. Participants were recruited from online support groups for individuals with Lyme disease, and completed an online questionnaire about their experience of OCS, Lyme disease characteristics, and the temporal relationship between these symptoms.

RESULTS

OCS were common, with 84% endorsing clinically significant symptoms, 26% of which endorsed symptoms onset during the six months following their Lyme disease diagnosis and another 51% believed their symptoms were temporally related. Despite the common occurrence of OCS, only 44% of these participants self-identified these symptoms as problematic. Greater frequency of Lyme disease symptoms and disease-related impairment was related to greater OCS. In the majority of cases, symptom onset was gradual, and responded well to psychological and pharmacological treatment. Around half of participants (51%) reported at least some improvement in OCS following antibiotic treatment.

CONCLUSIONS

This study highlights the common co-occurrence of OCS in patients with Lyme disease. It is unclear whether OCS are due to the direct physiological effects of Lyme disease or associated immunologic response, a psychological response to illness, a functional somatic syndrome, or some combination of these.

An overview of medical risk factors for childhood psychosis: Implications for research and treatment

OBJECTIVE

Psychotic disorders in childhood and early adolescence often progress to chronic schizophrenia, but in many cases there are diagnosable medical and genetic causes or risk factors. We reviewed our clinical experience and the relevant literature to identify these factors and to define their clinical features, appropriate work-up and treatment.

METHOD

We reviewed the results of comprehensive medical evaluations of 160 psychotic children and adolescents in our center. We also searched the Medline database (January 1994 to December 2015) with the following keywords and combinations: early onset schizophrenia, childhood onset schizophrenia, early onset psychosis, first episode psychosis, inborn errors of metabolism (IEM), genetic syndrome, copy number variants, autoimmune disorders, endocrine diseases, nutritional deficiencies, central nervous system infections, movement disorders, and epilepsy.

RESULTS

In our center, 12.5% of cases had medical disorders likely to be contributing to psychosis. Based on 66 relevant papers and our experience, we describe the clinical features of multiple genetic syndromes, IEM, and autoimmune, neurological, endocrinological and nutritional disorders that increase the risk of psychotic disorders in childhood and adolescence. We propose an algorithm for systematic laboratory evaluation, informed by clinical examination, emphasizing common and/or treatable factors.

CONCLUSIONS

In children and early adolescents with psychotic disorders, systematic medical work-up is warranted to identify medical and genetic factors. Not every rare cause can be worked up, thus careful clinical examinations are required to detect medical, neurological and genetic signs. Comprehensive medical evaluation can detect treatable diseases among cases of early-onset psychosis.

Neuropsychiatric Aspects of Infectious Diseases: An Update

Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system, human immunodeficiency virus infection, and AIDS.

A study of neuropsychiatric manifestations in patients of neurocysticercosis

BACKGROUND

Neurocysticercosis (NCC) is an endemic parasitic infection of Asia, Africa, Latin America, and central Europe. Neuropsychiatric manifestations of the illness include epilepsy and behavioral disturbances. There is a dearth of systematic studies on psychiatric manifestations of NCC from various Asian counties. The present study assessed the prevalence of various psychiatric disorders in a cohort of patients with NCC attending a neurological service.

MATERIALS AND METHODS

Detailed psychiatric assessment was carried out on 50 patients of NCC with epilepsy and 50 patients of epilepsy without any evidence of NCC. Comprehensive Psychopathological Rating Scale was used to elicit the symptoms. Cognitive functions were assessed using Mini Mental Status Examination. Psychiatric diagnoses were made as per International Classification of Diseases, 10(th) edition (ICD-10).

RESULTS

Sixty eight percent of the patients with NCC suffered from a psychiatric disorder, as compared to 44% of those without NCC (P=0.02). Major depression and mixed anxiety depression were the two most common diagnoses. None of the patients was to found to suffer from a psychotic disorder. The most frequent site of brain lesion of NCC was the parietal lobe, followed by frontal lobes and disseminated lesions. Left sided lesions were associated with greater psychiatric morbidity. Focal seizures with or without secondary generalizations were present more frequently in patients with NCC whereas primary generalized seizures were more common in patients with idiopathic epilepsy (P=0.05).

CONCLUSION

Psychiatric manifestations are more common in patients of epilepsy with NCC than those without NCC. The treating clinician need to be vigilant about the phenomenon.

The psychoimmunology of lyme/tick-borne diseases and its association with neuropsychiatric symptoms

Disease progression of neuropsychiatric symptoms in Lyme/tick-borne diseases can be better understood by greater attention to psychoimmunology. Although there are multiple contributors that provoke and weaken the immune system, infections and persistent infections are significant causes of pathological immune reactions. Immune mediated ef-fects are a significant contributor to the pathophysiological processes and disease progression. These immune effects in-clude persistent inflammation with cytokine effects and molecular mimicry and both of these mechanisms may be present at the same time in persistent infections. Sickness syndrome associated with interferon treatment and autoimmune limbic encephalopathies are models to understand inflammatory and molecular mimicry effects upon neuropsychiatric symp-toms. Progressive inflammatory reactions have been proposed as a model to explain disease progression in depression, psychosis, dementia, epilepsy, autism and other mental illnesses and pathophysiological changes have been associated with oxidative stress, excitotoxicity, changes in homocysteine metabolism and altered tryptophan catabolism. Lyme dis-ease has been associated with the proinflammatory cytokines IL-6, IL-8, IL-12, IL-18 and interferon-gamma, the chemokines CXCL12 and CXCL13 and increased levels proinflammatory lipoproteins. Borrelia burgdorferi surface gly-colipids and flagella antibodies appear to elicit anti-neuronal antibodies and anti-neuronal antibodies and Borrelia burgdorferi lipoproteins can disseminate from the periphery to inflame the brain. Autism spectrum disorders associated with Lyme/tick-borne diseases may be mediated by a combination of inflammatory and molecular mimicry mechanisms. Greater interaction is needed between infectious disease specialists, immunologists and psychiatrists to benefit from this awareness and to further understand these mechanisms.

The diagnostic spectrum in patients with suspected chronic Lyme neuroborreliosis--the experience from one year of a university hospital's Lyme neuroborreliosis outpatients clinic

BACKGROUND AND PURPOSE

Studies addressing the diagnostic relevance of anti-Borrelia burgdorferi (BB) serum antibodies in patients with non-specific symptoms and suspected chronic Lyme neuroborreliosis (LNB) are scarce.

METHODS

In this study, we enrolled within 1 year 122 patients with suspected chronic LNB. One hundred and fourteen patients had previously tested positive for BB. All patients had previously received antibiotic treatment. Each patient received a clinical examination and measurement of BB-specific antibodies. The diagnosis of neuroborreliosis was made according to the national guidelines of the German Society of Neurology. Nine patients had acute borreliosis. One of the nine met the criteria of acute LNB. Of the remaining 113 patients, 85 patients underwent a lumbar puncture. Ten seronegative subjects without lumbar puncture were also considered. In 61.8% of these 95 patients the quality of life, of sleep, mood, and anxiety were assessed.

RESULTS

Of 95 patients, 25.3% had symptoms without a somatic cause or evidence of borreliosis, 38.9% had a well-defined illness unrelated to BB infection, and 29.5% suffered from symptoms without a detectable somatic cause, displaying antibodies against BB. Six patients were grouped as post-LNB syndrome. Most common symptoms in all categories were arthralgia, myalgia, dysaesthesia, depressive mood and chronic fatigue.

CONCLUSION

Patients with persistent symptoms with elevated serum antibodies against BB but without signs of cerebrospinal fluid inflammation require further diagnostic examinations to exclude ongoing infection and to avoid co-infections and other treatable conditions (e.g. autoimmune diseases). One patient with acute LNB, who was treated with ceftriaxone for 3 weeks suffered from LNB with new headaches and persistent symptoms 6 months later. These data should encourage further studies with new experimental parameters.

Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis

Lyme disease has a worldwide distribution and is the most common vector-borne disease in the United States. Incidence, clinical manifestations, and presentations vary by geography, season, and recreational habits. Lyme neuroborreliosis (LNB) is neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi in the United States and by Borrelia garinii or Borrelia afzelii species in Europe. Enhanced awareness of the clinical presentation of Lyme disease allows inclusion of LNB in the imaging differential diagnosis of facial neuritis, multiple enhancing cranial nerves, enhancing noncompressive radiculitis, and pediatric leptomeningitis with white matter hyperintensities on MR imaging. The MR imaging white matter appearance of successfully treated LNB and multiple sclerosis display sufficient similarity to suggest a common autoimmune pathogenesis for both. This review highlights differences in the epidemiology, clinical manifestations, diagnosis, and management of Lyme disease in the United States, Europe, and Asia, with an emphasis on neurologic manifestations and neuroimaging.

Neuropsychiatric aspects of infectious diseases

Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system.

Motion-onset and pattern-reversal visual evoked potentials in diagnostics of neuroborreliosis

Neuroborreliosis is a form of borreliosis that affects the central and/or peripheral nervous system. Although it can mimic neurologic and ophthalmologic disorders such as multiple sclerosis and optic neuritis, visual evoked potential (VEP) examination is usually not used in neuroborreliosis diagnostics. Combined VEP testing (pattern-reversal VEPs and VEPs produced in response to linear and radial motion) was performed in 81 patients with neuroborreliosis verified by laboratory results (positive polymerase chain reaction or intrathecal antibodies production). Thirty-four patients reported diplopia or blurred vision related to borreliosis. In 33 (40%) patients the VEPs were delayed: motion-onset VEPs were pathologic in 22 (27%) patients, reversal VEPs in 5 (6%) patients, and both VEP types in 6 (7%) patients. The findings suggest that VEP testing (especially the motion-onset VEP testing) can confirm CNS involvement. Much higher sensitivity of motion-onset VEPs in comparison with reversal VEPs can result from rather selective (earlier) involvement of the magnocellular system or the dorsal stream of the visual pathway.

Seizures in a 20-month-old native of Minnesota: a case of neurocysticercosis

A 20-month-old child, native of Minnesota, was diagnosed with neurocysticercosis. He had no history of international travel or pork consumption. This case and review of the literature emphasize the need to consider neurocysticercosis in any child with nonfebrile seizures in the United States because international travel and exposure to international travelers have become so common throughout the world.

Anterior cingulate activation and error processing during interferon-alpha treatment

BACKGROUND

There has been increasing interest in the role of immunologic processes, notably cytokines, in the development of behavioral alterations, especially in medically ill patients. Interferon (IFN)-alpha is notorious for causing behavioral symptoms, including depression, fatigue, and cognitive dysfunction, and has been used to investigate the effects of cytokines on the brain.

METHODS

In the present study we assessed the effects of low-dose IFN-alpha on brain activity, using functional magnetic resonance imaging during a task of visuospatial attention in patients infected with hepatitis C virus (HCV).

RESULTS

Despite endorsing symptoms of impaired concentration and fatigue, IFN-alpha-treated patients (n = 10) exhibited task performance and activation of parietal and occipital brain regions similar to that seen in HCV-infected control subjects (n = 11). Interestingly, however, in contrast to control subjects, IFN-alpha-treated patients exhibited significant activation in the dorsal part of the anterior cingulate cortex (ACC), which highly correlated with the number of task-related errors. No such correlation was found in control subjects.

CONCLUSIONS

Consistent with the role of the ACC in conflict monitoring, ACC activation during IFN-alpha administration suggests that cytokines might increase processing conflict or reduce the threshold for conflict detection, thereby signaling the need to exert greater mental effort to maintain performance. Such alterations in ACC activity might in turn contribute to cytokine-induced behavioral changes.

Obsessive-compulsive disorder following brain injury: a review

OBJECTIVE

This article reviews obsessive-compulsive disorder (OCD) following acquired brain injury. OCD type symptomatology without any other cognitive, behavioral, or emotional problems following a brain injury appears to be rare. However, the first onset of obsessions and compulsions following a brain injury has been described, but cognitive impairments can potentially color the presentation.

METHOD

This article reviews obsessive-compulsive disorder (OCD) after brain injury, including traumatic brain injury, cerebrovascular accidents, brain tumors and brain infections. Overlapping symtomatology between OCD and brain injury is discussed.

RESULTS

Findings regarding the neuro-imaging of OCD after brain injury are reviewed and integrated with neuropsychological data from studies with idiopathic OCD.

CONCLUSION

There appears to be some convergance between findings from studies of the neuropsychology of idiopathic OCD and neuro-imaging of OCD following brain injury.

Practitioner review: early adversity and developmental disorders

BACKGROUND

Knowledge of genetic influences, on developmental disorders such as autism spectrum, attention deficit/hyperactivity disorder and learning disabilities, has increased the opportunities for understanding the influences of the early environment.

METHODS

This paper provides a selective, narrative review for clinicians of the effects of factors such as exposure to toxins and stresses in utero and in postnatal life; brain injuries and perinatal compromise; neglect, malnutrition and selective food deficiencies. It also considers what is known about the mechanisms through which early adversities operate.

RESULTS

Gaps in the research are identified and suggestions made about clinical investigations. Several types of environmental adversity have associations with later disorders that suggest a causal role. The effects are often on a broad range of psychological processes, and are not always quickly reversible. Several adversities often coexist, calling for skilled judgement about priorities in treatment.

CONCLUSIONS

Individuals vary considerably in their exposure to adversity and their vulnerability to its effects, and genetic inheritance can influence both.

Diagnosis, treatment and control of Taenia solium cysticercosis

PURPOSE OF REVIEW

Taenia solium taeniasis/cysticercosis is now recognized as a major public health problem in most developing countries because of its association with seizures. Major advances in the diagnosis and epidemiology of taeniasis/cysticercosis have occurred in recent years. However, despite abundant literature on the subject, many questions remain unanswered including the role of anti-parasitic therapy and the potential for long-term control or elimination of the disease in field conditions following active interventions.

RECENT FINDINGS

Recent advances have included improved knowledge of the availability and optimization of diagnostic tools for the tapeworm stage, a better understanding of the meaning of antibody serology, the introduction of antigen detection assays, a consensus on the use of antiparasitic medication, awareness of inflammation and chronic scars around calcified cysts, population-based neuroimaging studies, application of control measures, and progress in the development of a pig vaccine.

SUMMARY

Neurocysticercosis is now much better understood than it was a few years ago. Infection and disease are now classified in terms of parasite viability, resulting in multiple and diverse clinical entities, each of which has a proper prognosis and management. As a result of this, the interpretation of diagnostic assays and imaging examinations is much more coherent. New aspects of this interesting disease have been recognized, mainly in relation to the frequency of calcified neurocysticercosis and its potential association with symptomatic relapses. Consensus diagnostic and treatment schemes have been proposed, and promising alternatives for control are currently being tested in several countries.

Central nervous system Lyme disease

Lyme disease is a disease caused by the spirochete, Borrelia burgdorferi. It is transmitted to humans via a bite from an infected tick. It has several classic stages or categories of illness, including early localized disease, early disseminated disease, and late disease. The focus of this article is on the manifestations, diagnosis, and treatment of Lyme disease of the central nervous system.