Title : A case of acute disseminated encephalomyelitis presenting with catatonia and psychosis in a patient with schizophrenia
Abstract:
Introduction: Acute disseminated encephalomyelitis (ADEM) is a rare, immune-mediated inflammatory disorder of the central nervous system (CNS) characterized by multifocal neurological deficits and encephalopathy. Often triggered by infections or vaccinations, ADEM primarily affects the white matter and can present with symptoms such as altered mental status, motor deficits, ataxia, and seizures. While neurological features are well recognized, psychiatric symptoms—including psychosis, mood disturbances, and catatonia—are less commonly associated with ADEM and may lead to diagnostic challenges, especially in patients with preexisting psychiatric disorders.
Psychotic disorders, particularly schizophrenia, can share overlapping features with ADEM, complicating the clinical picture. Symptoms such as hallucinations, delusions, catatonia, and cognitive impairment can be attributed to either a primary psychiatric illness or an underlying neuroinflammatory process. In psychiatric inpatient settings, organic causes of psychiatric symptoms may be overlooked, especially when a patient carries a longstanding psychiatric diagnosis. This can delay appropriate recognition and management of conditions with neurological involvement.
We present the case of a patient with a history of schizophrenia who was admitted to an inpatient psychiatric unit for catatonia. Upon further review of his medical records, it was discovered that he also had a diagnosis of ADEM. This case highlights the clinical overlap between ADEM and psychiatric disorders, the challenges of distinguishing neuroinflammatory from primary psychiatric presentations, and the importance of thorough medical evaluation in psychiatric settings.
Case Presentation: A 24-year-old male with a history of schizophrenia, conduct disorder, disruptive mood dysregulation disorder (DMDD), and cannabis use disorder was brought to the emergency department via mobile crisis response after being found wandering barefoot in cold weather with altered mental status. Initial evaluation revealed aspiration pneumonia on chest CT, and he was admitted for medical management. During his hospitalization, the patient exhibited significant agitation, requiring restraints and PRN medications for elopement attempts. Once medically stabilized, he was transferred to inpatient psychiatry due to worsening psychosis, marked by disorganized thoughts, nonsensical speech, and frequent right-to-left internal stimulation (RTIS). Upon arrival, he developed profound catatonia, presenting with mutism, bizarre facial expressions, fixed gaze, and motor rigidity. He demonstrated a greater than 50% improvement with an Ativan challenge, leading to scheduled benzodiazepine treatment. His psychiatric medications—including clozapine, lithium, Depakote, benztropine, and Ativan—had been resumed on the medical floor after family-reported adherence; however, given concerns about noncompliance prior to admission and the risk of antipsychotic-induced worsening of catatonia, they were held. His condition required careful medication titration, with daily Haloperidol 1mg due to ongoing psychosis with command auditory hallucinations. During his admission, a chart review revealed a prior diagnosis of acute disseminated encephalomyelitis (ADEM), raising critical questions regarding the interplay between his neuroinflammatory and psychiatric conditions.
Discussion: Acute disseminated encephalomyelitis (ADEM) is a rare neuroinflammatory disorder that typically presents with encephalopathy and neurological deficits. However, psychiatric symptoms, including psychosis and catatonia, can also be prominent, complicating diagnosis, especially in patients with preexisting psychiatric disorders. This case highlights a patient with schizophrenia who exhibited worsening psychosis, catatonia, and functional decline, raising concerns for an acute psychiatric exacerbation. However, the concurrent presence of ADEM in this patient raises important questions about the role of neuroinflammation in psychosis and the difficulty in distinguishing between primary psychiatric illness and neurological disease. This case contributes to the growing recognition of psychiatric manifestations of ADEM and underscores the need for clinicians to consider neuroinflammatory disorders when evaluating atypical psychiatric presentations.
Highlights:
- ADEM, a neuroinflammatory disorder, can present with prominent psychiatric symptoms, including psychosis and catatonia.
- Distinguishing between primary psychotic disorders and ADEM can be challenging due to overlapping symptoms.
- This case illustrates how a patient with schizophrenia also had ADEM, raising questions about the interplay between neuroinflammation and psychiatric illness.
- Awareness of ADEM as a potential cause of psychosis is important, especially in patients with treatment-resistant or atypical psychiatric symptoms.
- Neuroimaging and neurological evaluation may be valuable in psychiatric patients with unusual symptom presentations.
Plain language summary: Psychosis is typically associated with psychiatric conditions like schizophrenia, but sometimes brain inflammation can cause similar symptoms. This case describes a young man with schizophrenia who was hospitalized due to worsening psychosis and catatonia. While his symptoms were initially assumed to be part of his psychiatric illness, he also had a rare brain inflammation disorder called acute disseminated encephalomyelitis (ADEM). Since both schizophrenia and ADEM can cause hallucinations, delusions, and disorganized thinking, it can be difficult to tell them apart. This case highlights how ADEM can mimic psychosis and suggests that brain inflammation may play a role in psychiatric disorders. Recognizing the neurological aspects of psychiatric symptoms could lead to better treatment approaches.
Keywords: Acute disseminated encephalomyelitis, Psychosis, Catatonia, Schizophrenia, Neuroinflammation, White matter disease, Autoimmune encephalitis, Psychiatric symptoms, Neurology-psychiatry interface.
