History: a ‘negative’ view
Mr. J, a 50-year-old native of Fiji, has had depression and substance abuse disorder for more than 10 years, marked by irritability, poor sleep, hopelessness, and suicidality. He also suffered a traumatic brain injury in the military 25 years ago.
Police bring Mr. J to the ER after they find him wandering near traffic and speaking incoherently. His feet and hands jerk on the way to the hospital, leading police to suspect that Mr. J has suffered a grand mal seizure.
In the ER, Mr. J appears confused, has visual hallucinations, and moves his hands and feet involuntarily. His head and arms move erratically during the ER psychiatrist’s interview, and he says that his pelvis is arching forward and preventing him from walking steadily. The day before, he says, he saw frightening “visions” of a being who looked “like a photo negative.”
Mr. J has been seeing an outpatient psychiatrist, who has prescribed citalopram, 40 mg/d, for depression and clonazepam, 1 mg three times daily, for related anxiety symptoms.
The patient is disoriented and inattentive during the mental status examination. His cognitive deficits fluctuate in severity; at times he is aware of his surroundings, then suddenly loses this awareness.
Vital signs are stable. Physical exam shows Mr. J is approximately 30 lb underweight (97 lb) with a body mass index of 16.9 kg/m2—nearly 2 kg/m2 below normal. He says he has been skipping meals because of poor appetite. He also has strikingly lizard-like, scaly skin.
Urine drug screen shows no signs of recent alcohol or substance abuse. Complete metabolic profile shows elevated liver enzymes, suggesting alcohol or illicit substance toxicity, medication toxicity, hepatitis, thyroid disorder, muscle disease, or a rare liver condition. EEG shows mild encephalopathy but no ictal activity.
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The authors’ observations
Our psychiatric differential diagnosis is broad:
- visual and auditory hallucinations are concurrent in numerous disorders, including schizophrenia and depression
- visual hallucinations alone suggest dementia, delirium, or psychosis resulting from a medical condition, medication, or substance(s) of abuse1
- Mr. J’s past head injury increases his risk of dementia and delirium
- his abrupt symptom onset and inattention suggest delirium.
Choreoathetosis can result from:
- medications such as stimulants and levodopa
- toxins
- systemic diseases such as systemic lupus erythematosus, thyrotoxicosis, or stroke
- degenerative brain diseases such as Huntington’s disease
- or focal brain diseases such as tumors.2
Although the test results narrow the differential diagnosis, we still have to consider numerous medical conditions that can cause delirium, such as trauma, cerebral vascular accident, intracerebral masses, CNS infection, and inflammatory disease.
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History: collateral contributions
We refer Mr. J for lumbar puncture to rule out CNS infection and MRI to rule out tumor, abscess, or other structural brain abnormalities that could cause seizure. Results are unremarkable.
We then speak with Mr. J’s outpatient psychiatrist, who reports that Mr. J has had no residual cognitive impairment from his head injury. She adds, though, that he often develops cognitive problems after consuming large amounts of a traditional South Pacific beverage containing kava (Piper methysticum). She explains that Mr. J socializes with fellow Fijians who drink kava at gatherings, and that he often drinks kava to excess. She attributes his dry, scaly skin to excessive kava use.
Upon questioning, Mr. J says he consumes about a half-pound of kava root per day. He says he uses the root to make a tea-like beverage that, like alcohol, induces euphoria and relaxation. He says he began doing this in his youth back in Fiji, and now drinks “many cups” of kava per day.
Mr. J states that his current episode of strange movements and visual hallucinations began hours after he drank several cups of kava the day before police brought him to the ER. He considers his new psychiatric symptoms Jesus’ punishment for drinking kava.
The authors’ observations
Mr. J’s persecutory delusions suggest that he does not fully associate his symptoms with excessive kava use, but his abnormal movements, weight loss, skin changes, liver function abnormalities, and mental status changes are known adverse effects of kava.3 We diagnose substance-induced delirium rather than substance intoxication or substance-induced psychosis because: