Department Case Conference Date: 14th Feb 2002

1. DEPARTMENTAL CASE
CONFERENCE
Psychotic Disorder due to
Post-viral Encephalitis
Presenter: Dr Zahiruddin
14/02/2002

2. Personal Identification
 Name: NAK
 Age: 18 years (DOB 25/8/83)
 Address:
 Date of admission: 19/08/2001

3. Chief Complaint
 2 months history of:
being withdrawn and quiet
neglecting of personal hygiene
being distressed by voices
refusal to eat & drink as usual

4. History of Present Illness
 She was quite stable with medication until end
of June 2001.
 No apparent stressor was noted
 Gradually became withdrawn and quiet.
Parents need to ask her many times before eliciting a
verbal response from her
Did not mix with other siblings as usual
Tend to sit in one place for hours and only moved
when instructed to.

5. History of Present Illness
 Neglecting her personal need & care
Described by mother as “pelupa”, did not care of her
well-being, unable to tell the time of the day.
All personal care need to be instructed by others – the
caregiver had to repeat it several times before she
made her move.
Even for basic need like PU need instruction. If not
urged to eat she will not.

6. History of Present Illness
 Hearing voices
Hallucinatory behavior seen – smiling, laughing &
crying to self
She heard commenting and commanding voices
which she had told the mother.
Tendency to obey the commanding voices –
commanded her not to do things.
Distressed by the voices which said bad things about
the mother and instructed her to hit her.

7. History of Present Illness
 Refusal to drink and eat adequately
In the past, this had led to admission into pediatric
ward in 1994
More of passive rather than active refusal.
Refusal was related to commanding voices. No
specific belief regarding the food was noted.

8. History of Present Illness
 She was followed-up more frequently and the
dosage of medication was increased. Despite
these measures, there was little if any
improvement was noted. She was advised for
admission on 19/08/01.

9. History of Present Illness
 There was clear deterioration of psychosocial
functioning during the 2 months period.
 Previously, while she was in remission, in
addition to being able to look after herself she
was able to look after the 2 toddler siblings and
do simple house chores eg, cooking and
washing.

10. Past Medical History
 History of viral encephalitis at 11 years old
 Gradual loss of consciousness following a high grade
fever and headache for 1/7 (May 94)
D1- she was alert
D2 - speech became incoherent but still recognizing family
members. Admitted to GHKB. Complete LOC after LP.
Incontinence. Developed generalized tonic clonic convulsion
few times.
Comatose for 2 days in decorticate posturing. Admitted to ICU
with intubation about 9 days.
 treated with acyclovir, CMC and ampicillin

11. Past Medical History
 CSF findings
biochemistry: clear, glucose 5.8, protein 0.95
RBC 180/hpf, lymphocytes 9/hpf
latex -ve.
Virology: EBV IgM -ve, Jap B IgM -ve & Herpes simplex IgM not
ready
 CT scan findings
some bilateral hypodense areas in the temporal region. No SOL
or hemorrhages seen. Features does not suggest bacterial
meningitis

12. Past Medical History
 2nd admission to pediatric ward July 94 about 9 days.
Reason was refusal of food and drink for 1 week. Spit
out water/food if forced by the mother. Mutism -
indicate needs by pointing or nodding head.
 Speech, occupational therapist & psychiatric referrals.

13. Past Psychiatric History
 1st contact was on 13th July94
Changes in behavior such as inability to take care of self,
take food independently, talk properly (reduced to simple
words such as “ma”, “ayah” etc and pacing up & down in
the house without reason.
Hallucinatory behavior - walking around, touching object or
things along the way.
Started on tab haloperidol 0.75mg daily. Noted
improvement during outpatient follow-up.

14. Past Psychiatric History
 In August96, she was thought to be depressed with
scholastic problems.
HPL was tapered down and replaced with AMT 10mg
However, she became more disturbed for 2 weeks - poor sleep,
crying without reason throughout the day & night, talking to
herself & worst at night which responded well to HPL 0.5mg
EOD.
 By late 1997, has developed sufficient verbal skill to
complain auditory hallucinations and persecutory ideas
& reference to treating doctor.

15. Past Personal History
 Prenatal history was uneventful. Normal hospital
delivery.
 Early childhood: No delayed developmental
milestones. No severe illness. No h/o bed
wetting/soiling, night terrors or thumb sucking.
 Middle childhood: No conduct problem. Schooling well.
Good academic achievement - often got 1st place in
class

16. Past Personal History
 Later childhood:
frequent school absenteeism. Refused to sit for
exams. Poor attention in classroom. Unmotivated to
assignments given.
Socially acceptable - no aggression
Due to poor scholastic performance she was referred
to special education class after completing std 6

17. Past Personal History
Kelas Khas Bermasalah Pendidikan Menengah
(KKBPM), SM Tanjong Mas for 2 yrs.
School refusal was associated with taunt by
classmates who branded her as “bodoh”
Did not sit for UPSR or PMR

18. School Report 22/6/96
 Akademik
Kurang minat dalam menghadapi pelajaran dan pembelajaran
lemah dan susah memahami dalam pembelajaran terutamaL
matapelajaran Bahasa Inggeris dan Bahasa Melayu
Tidak menduduki ujian dan latihan setiap kali diadakan dengan alasan
sakit kepala.
 Tingkahlaku
Perangai-memuaskan. Kehadiran ke sekolah- tidak memuaskan
 Pergaulan
Dengan rakan sekelas baik dan mesra. Dengan guru-guru baik dan
memuaskan

19. Past Personal History
 Premorbid Personality
Sociable, well mannered, warm to other siblings
 Habit
No history of illicit substance use.
Fill her past times watching TV drama / movies and
occasionally read comic books.
Not many friends nowadays

20. Family History
 Father: 51 y.o. Pembantu Kesihatan Awam
 Mother: 43 y.o. Non-consanguinous marriage
 1st sib: 21 y.o. sister
 2nd sib: patient
 3rd sib: 14 y.o. sister
 4th sib: died after birth due to ?sepsis
 5th sib: 9 y.o. brother
 6th sib: 3 y.o.
 7th sib: 1 ½ y.o.
No family history of mental illness

21. Mental Status Examination
 General description
plump, well groomed, young Malay girl in hospital
attire.
Slow to response and tend to do things slowly unless
urged. No mannerism, stereotypes or abnormal gait
slow speech. Often whispered, hesitant and
suggestive. No slurred, stuttering or echolalia.
Cooperative with good rapport.

22. Mental Status Examination
 Mood, feeling & affect:
euthymic mood
restricted affect. No lability
appropriateness: mostly okay. No distress shown
when she was unable to give correct answer
Perceptual disturbances
auditory hallucination but detail not provided
no depersonalization or derealization elicited

23. Mental Status Examination
 Thought process
lack of spontaneity and paucity of ideas. Answers are
relevant and logical. No tangentiality. Perseverance or
neologism
no preoccupation or delusions elicited.
Abstract thinking: knew some idioms though not accurate
eg, kaki ayam=tak pakai selipar, tangkai jering=orang
yang sombong, kepala angin=tak boleh pegang rahsia.
Concrete understanding of proverb “diluah mati emak,
ditelan mati ayah”=anak derhaka. Unable to do
similarities & differences

24. Sensorium & Cognition
 Consciousness: Alert
 Orientation: Generally ok but missed the
details
 Concentration: unable to do serial subtraction
test 100-7 or 20-3. Able to do day or month
forward but not backward as well as spelling
backward.

25. Sensorium & Cognition
 Memory
Immediate retention & recall: intact
Recent memory: remembers lunch & breakfast.
Remote: remembers address, date of birth, house
telephone number.
 Information & intelligence
Calculation: poor eg. 2+3=5, 7+8=9, 5-2=3, 10-7=6,
2x5=25, 4x3=6, 10/2=1 & 6/3=3.

26. Sensorium & Cognition
General knowledge: knows the location of towns such
as Besut, Kuantan, Shah Alam, Muar, Kuala Pilah
and Kuching. Knows the PM and CM of Kelantan.
She said DPM is DSAI.
 Judgement
Social & personal: impaired
Test: intact
 Insight: poor

27. Mini-Mental State Examination
 Orientation 5/10
y:2001, m:August, d:25th, day:Monday, season: rainy
state:Kelantan, county:?, town:K Kerian, floor:2nd,
building:hospital ( wad biasa)
 Registration 3/3
 Attention & calculation 0/5
 Recall 0/3 (with cuing 3/3)

28. Mini-Mental State Examination
 Language 7/9
naming 2/2
repetition 1/1
three-stage command 2/3
reading 1/1
writing 1/1
drawing 0/1
 Total: 16/30

29. Physical Examination
 Generally healthy young female. No pallor,
jaundice or stigmata of chronic diseases.
BP=120/70 PR=80bpm.
 Neurological examination: All cranial nerves
were intact. No pyramidal signs and localizing
sings.
 Other systems were essentially normal

30. Neurological Soft Signs
 Positive tests: finger tapping, rapid alternating
movements, finger to nose, heel to shin,
tandem walking, tandem walking backward &
graphesthesia
 Negative tests: foot tapping, eye closure,
tongue extrusion, arm extended, heel walking,
toe walking, standing on one foot, hopping on
one foot & Rhomberg’s sign.

31. Electroencephalography (EEG)
 Alert background wave
 Well organized with posterior alpha activity 7-
9Hz 20-30 microvolt. Good anteroposterior
progression.
 No spike wave seen.

32. Electroencephalography 19/5/94
 Background activity
very slow background with high voltage at < 1Hz. This is typical
of encephalitis
 Paroxysmal activity
generalized bursts of epileptic discharges seen throughout
recordings
 Activation procedures
no features to suggest herpes
 Conclusion
encephalopathic EEG with generalized epilepsy changes. No
features specific of herpes but this cant be ruled out on EEG

33. Electroencephalography 6/9/94
 Background activity
Semiconscious recording. Child on phenytoin. The background is
slow with posterior dominant rhythm of 5Hz seen bilaterally
and voltage of 40-50 microvolt. Slower burst of delta, high
voltage also seen presumed lapses into drowsiness.
 Paroxysmal activity
 Activation procedures
no epileptic activities noted
 Conclusion
marked improvement from previous recording with a lot more
awake charges and no epileptic activities.

34. IQ Testing
 SFB test twice in March 96. IQ 56 (mild MR)
 Repeat test in April 97
Respond to question delayed. Her attention can be aroused but
difficult to sustain.
On BG drawings, it shows inadequate perceptual organization.
Difficulty in angulations and disturbance of figure present.
On Stanford-Binet test, her MA was found to be 8 years. IQ being
61. Her present intellectual efficiency is functioning at Mild MR
level with presence of organicity.

35. Summary
18 y.o. single Malay girl who presented with hearing
voices, neglecting personal hygiene and food/drink
refusal for 2 months. Similar presentation occurred for
the first time 2 months after viral encephalitis for which
the symptoms remitted with low dose antipsychotic but
the scholastic problem persisted. Second episode
occurred after HPL was stopped temporarily. Perinatal
and early childhood period was normal. Good
academic achievement prior to encephalitis..

36. Summary
 There was no family history of mental illness among
immediate family members. MSE revealed reduced
psychomotor activity, slow non-spontaneous and
paucity of speech, inappropriate affect, auditory
hallucination and concrete thinking. Cognitively has
poor orientation, concentration and arithmetic skills.
Memory was average. MMSE was 16/30. PE showed
soft signs but no localizing signs. EEG was normal

37. Provisional Diagnosis
 Axis I: Psychotic disorder due to post-viral
encephalitis.
 Axis II: mild mental retardation
 Axis III: none
 Axis IV: none
 Axis V: GAF 15 (on admission), GAF 65
(highest level past year)

38. DSM-IV
Diagnostic Criteria for Psychotic Disorder Due to GMC
A. Prominent hallucination and delusions
B. There is evidence from the history, PE, or laboratory
findings that the disturbance is the direct
physiological consequence of a GMC
C. The disturbance is not better accounted by another
mental disorder
D. The disturbance does not occur exclusively during the
course of a delirium.

39. Things to consider in determining whether the psychotic
disturbance is due to GMC
1. Etiologically related through physiological mechanism
(plausibility)
2. Cause precedes effect (temporality)
3. Atypical features of primary disorder (specificity)
(Others consistency, strength, dose-response,
reversibility)

40. Differential Diagnoses
 Schizophrenia
 Dementia
 293.89 Catatonic disorder due to post-viral
encephalitis

41. DISCUSSION
Encephalitis &
Psychosis

42. Limbic Encephalitis
 Limbic encephalitis is most associated with psychotic
symptoms.
 Viruses such as HS, CMV, varicella-zoster, measles,
mumps, arbovirus are known to home into the frontal
cortex or the inferior medial temporal lobe and
orbitofrontal cortex resulting in behavior disturbances
(Adams & Victor 1984)
 These behavioral symptoms are presumably due to
perturbances in neurotransmitter function without the
evidence of clinical and pathological inflammation
(Liebowitz 1983)

43. Paraneoplastic Encephalopathies
 Uncommon poorly understood complication of
non-CNS tumour
 It can rarely cause schizophrenic symptoms
seemingly mediated by limbic inflammation
(Van Sweden 1986)

44. Herpes Simplex Encephalitis
 One of the commonest single cause of severe sporadic
encephalitis in about 20% in Britain.
 High mortality, and shows special features including
marked psychological disturbances both in acute
phase and a major sequel.
 Typically rapid onset with severe illness in acute stage.
Pyrexia up to 39.5, fits are frequent, meningeal
irritation, drowsiness & global confusion are common.
 MR can ensues in children or dementia in adult.
 Kluver-Bucy syndrome and Korsakoff-like syndrome
has been reported.