ABSTRACT Case presentation A 23-year-old Malay man presented on 9 January 2012 with a 2-day histo... more ABSTRACT Case presentation A 23-year-old Malay man presented on 9 January 2012 with a 2-day history of abnormal behavior, fever and two episodes of generalized tonic-clonic seizures during a family trip to Phuket, Thailand. He was a known case of bipolar type I disorder, diagnosed in 2010. He had a total of three hospital admissions in the past. However, he had stopped his treatment in December 2010 due to extrapyramidal side-effects (body stiffness) and weight gain while on risperidone. There was no history of substance abuse and no family history of mental illness. He was admitted to a medical ward and was treated for viral meningoencephalitis based on clinical presentation (fever, episodes of seizures), serologically positive for Herpes simplex virus (HSV) immunoglo-bulin (Ig)G and cytomegalovirus IgG, with raised infection parameters such as C-reactive protein (CRP) of 1.62 mg/dL and white blood cell count (WBC) of 14.7 ¥ 10 9 /L with predominant neutrophils of 12.8 ¥ 10 9 /L. Computed tomography (CT), mag-netic resonance imaging (MRI) of the brain, cere-brospinal fluid (CSF) and electroencephalogram (EEG) showed no significant abnormalities. His creatine kinase (CK) was raised at 2720 U/L. Urine for drugs was negative. Ceftriaxone 2 g b.i.d., phenytoin 100 mg t.d.s., acyclovir 500 mg t.d.s. were adminis-trated i.v. for 14 days. He was discharged well on 23 January 2012 with lorazepam 0.5 mg p.r.n., risperi-done 0.5 mg o.d., phenytoin 300 mg t.d.s. and folic acid 5 mg o.d. However, he was readmitted 3 days after dis-charge with complaints of insomnia, pacing up and down at home for 2 days, followed by depressed mood with neglected self-hygiene and being mute. He had not been taking risperidone as prescribed even in the ward as the family did not purchase the medication. Mental state examination showed a perplexed looking young man, in stupor, with presence of waxy flexibility, "psychological pillow" and restricted affect. Delusions and hallucinations could not be elicited. Physical examination revealed pyrexia with tempera-ture ranging from 37.8–38°C, labile blood pressure ranging 108–168/55–90 mmHg, heart rate ranging 60–140 b.p.m. and respiratory rate of 18 b.p.m. Glasgow Coma Scale score was 15/15. Neurological examination showed that he had hypertonia with cog-wheel rigidity and hyperreflexia on bilateral upper and lower limbs. The repeat CSF examination was bs_bs_banner
ABSTRACT Case presentation A 23-year-old Malay man presented on 9 January 2012 with a 2-day histo... more ABSTRACT Case presentation A 23-year-old Malay man presented on 9 January 2012 with a 2-day history of abnormal behavior, fever and two episodes of generalized tonic-clonic seizures during a family trip to Phuket, Thailand. He was a known case of bipolar type I disorder, diagnosed in 2010. He had a total of three hospital admissions in the past. However, he had stopped his treatment in December 2010 due to extrapyramidal side-effects (body stiffness) and weight gain while on risperidone. There was no history of substance abuse and no family history of mental illness. He was admitted to a medical ward and was treated for viral meningoencephalitis based on clinical presentation (fever, episodes of seizures), serologically positive for Herpes simplex virus (HSV) immunoglo-bulin (Ig)G and cytomegalovirus IgG, with raised infection parameters such as C-reactive protein (CRP) of 1.62 mg/dL and white blood cell count (WBC) of 14.7 ¥ 10 9 /L with predominant neutrophils of 12.8 ¥ 10 9 /L. Computed tomography (CT), mag-netic resonance imaging (MRI) of the brain, cere-brospinal fluid (CSF) and electroencephalogram (EEG) showed no significant abnormalities. His creatine kinase (CK) was raised at 2720 U/L. Urine for drugs was negative. Ceftriaxone 2 g b.i.d., phenytoin 100 mg t.d.s., acyclovir 500 mg t.d.s. were adminis-trated i.v. for 14 days. He was discharged well on 23 January 2012 with lorazepam 0.5 mg p.r.n., risperi-done 0.5 mg o.d., phenytoin 300 mg t.d.s. and folic acid 5 mg o.d. However, he was readmitted 3 days after dis-charge with complaints of insomnia, pacing up and down at home for 2 days, followed by depressed mood with neglected self-hygiene and being mute. He had not been taking risperidone as prescribed even in the ward as the family did not purchase the medication. Mental state examination showed a perplexed looking young man, in stupor, with presence of waxy flexibility, "psychological pillow" and restricted affect. Delusions and hallucinations could not be elicited. Physical examination revealed pyrexia with tempera-ture ranging from 37.8–38°C, labile blood pressure ranging 108–168/55–90 mmHg, heart rate ranging 60–140 b.p.m. and respiratory rate of 18 b.p.m. Glasgow Coma Scale score was 15/15. Neurological examination showed that he had hypertonia with cog-wheel rigidity and hyperreflexia on bilateral upper and lower limbs. The repeat CSF examination was bs_bs_banner
Uploads
Papers by Joshua Eu