A 73–year–old man, with a past history of coronary artery disease, s/p CABG, end stage renal disease on hemodialysis and aortic stenosis status post bioprosthetic aortic valve replacement 3 years prior. Presented to the ED for an altered mental status. For 2 days prior, was increasingly convinced that his wife was working with the CIA and that they were trying to kill him. He expressed the same concern in regards to the hospital staff. The patient had no history of psychiatric illness. More thorough investigation of his medical history revealed 2 episodes of fever at dialysis in the past month. Cultures were negative and treatment consisted of a single dose of vancomycin. He had also received two steroid injections, in the lower back and knee, for relief of chronic pain. The pain was successfully relieved. On exam his temperature was 100.9 F, vitals were normal. Labwork revealed leukocytosis – WBC 23,000, macrocytic anemia with hemoglobin 10.7 g/dL, and CT of the head did not reveal any pathology. Psychiatry consult was called and recommended continuing one–to–one supervision and Haldol for treatment of acute onset of fixed paranoid delusion. Given the leukocytosis and high risk of infection in a dialysis patient, blood cultures were drawn and empiric broad–spectrum antibiotics were started with Vancomycin, Cefepime and a single dose of Gentamicin. Blood cultures quickly grew Enterococcus faecalis. MRI of the head revealed multiple scattered scattered focal lesions consistent with embolic infarcts. Echocardiography showed a vegetation on the aortic valve. Additional embolic foci were found in the lung, spleen, psoas muscle and vertebrae. After 1 week in the hospital on IV antibiotics, leukocytosis had normalized, the patient was consistently afebrile, and Haldol was tapered and discontinued as the patient’s delusions had resolved. He was discharged to on Unasyn and Gentamicin. The plan was to continue the antibiotics for an 8 week course.
This fascinating patient’s entire presentation was related to psychiatric symptoms. He was found to have a low grade fever, an elevated WBC, and no obvious source of infection. A high level of suspicion in a dialysis patient led to aggressive immediate treatment that may have prevented further complications. Cultures grew quickly, and subsequently testing revealed wide spread septic emboli from endocarditis. The brain emboli appear to be the etiology of his fixed paranoid delusion. Appropriate intravenous antibiotics lead to successful resolution of the delusions.
Common and severe organic diseases such as bacterial endocarditis may initially present with exclusively psychiatric manifestations in patients with no prior psychiatric history. Changes in mental status, ranging from acute delirium to fixed delusions as in the case above, warrant a work–up for organic causes, including but not limited to, neoplastic diseases, metabolic derangement, nutritional/vitamin deficiency, and infection.